Nursing errors I learned from... - page 2

OK, to offset the thread "What was the most incompetent thing you ever saw a coworker do" I will start this thread. How many out there are brave enough to admit to mistakes they have made, and what... Read More

  1. by   Brownms46
    I recently made a med error, and gave Darvocet N instead of Lortab. How did this happen? I returned from break one nite to find out ...that the Lortab I had taken out of a baggie that was labeled Lortab 5, was really DCN and had been placed in the wrong bag!. I always take the med sheet to the narcotic box, and using the med sheet transcribe the name and sign out the drug on the narc sheet and the med sheet at the same time. I make sure that the count I have prior to taking the med is the amount stated on the narc sheet. I never even thought to look on the back of the med to confirm it was indeed Lortab. I quickly checked on the pt. to make sure no adverse reactions, and there was none. I called the MD, explained the error, and took full responsibity for giving the wrong med. The physican was very nice...and said..ok. I wrote out an incident report, and check on the pt hourly. The next morning, he said he had slept the best he had ever slept, and had no complaints and no adverse reactions.


    Althought I take full responsiblity for my error, I must also point out that 8 other nurses made the same error, and although the narcs were counted twice that day..no one picked on the error! Someone had picked up the meds from pharmacy at 1000 hrs that day and placed them in the wrong bags! When counting now...I make sure all meds in each box or bags is actually the med that is stated on that box or bag! I usually look at all meds, IVF and make sure I have what I think I have. But for some reason I looked at the ambien 5...but not the DCN! This was very upsetting...as I try very hard to make sure I do the 5R's every time I give meds...and I check and re-check...even if I'm about to go down the hall with a med...sometimes I will go back and check again...just to make sure! You can believe this one won't happen to me again!!!

    I must also add...that another "nurse" and I use the term loosely....gave Lortab before the error was found...and lied about what she gave! She stated she gave the correct med...but if she had given the correct med...how come the meds were still in the wrong bags?? If she got DCN out of the Lortab bag...why didn't she notify anyone that the meds were in the wrong bags??? Like I said...I use the term "nurse" loosely! If you're wrong...you're wrong...and should own up to it!
    Pride is a terrible thing...when it stops you from admitting an error!
    Last edit by Brownms46 on Jun 9, '02
  2. by   Sleepyeyes
    When I was a patient once, about 19 years old, I was in a w/c in the hallway awaiting transport for a sigmoidoscopy and along came a nurse, who shot some yellow stuff into the IV bag, and left. The yellow stuff hung out near the bottom of the bag, and within a minute or two I felt this horrible burning sensation going up my arm. The burning got up to about my shoulder before I flagged someone down and told them what was happening.
    She stopped the IV and shook up the bag, changed the tubing and restarted it.
    What was the yellow stuff?
    KCl.
    That's when I learned to NEVER bolus straight KCl.

    And y'all wonder why I believe in God.... :chuckle:
    Last edit by Sleepyeyes on Jun 9, '02
  3. by   mattsmom81
    KCL is yellow somewhere? I thought only MVI was yellow...

    Countless times I have hooked an IV piggyback antibiotic up via gravity then found later I forgot to unclamp the roller...patient missed his ABX dose. I do a double check on it now.

    I never ask a charge nurse to call a doctor for orders for me anymore. I've had too many problems with wrong info getting relayed. Unless it's a really basic thing, like 'the patient wants a sleeper...how about a Restoril order prn'...I call the doc myself.

    I always document my med errors, and when i catch an error by a coworker, my policy is to ask them to write it up themselves. That way they remember and learn from it, and taking responsibility. I HATE writing other nurses up. Of course if the nurse chooses NOT to do it then I have no choice.

    Ya'll are right...it is a professional duty to admit a mistake honestly and learn from it. Boy, docs sure don't do this do they....they 'bury their mistakes'.
  4. by   SmilingBluEyes
    Ok here is one......stupid me.

    It was about 3 years ago....postpartum patient I inherited from day shift. Her IV is out, she is eating, drinking, appears to be doing ok. I have not done her vital signs yet, but I make the ASSumption she had been up to pee since delivery. welp no. Her call lite goes off.... "I need to go pee bad!"

    So, I take my pregnant HUGE body over there to help her....thinking "no biggie". She weighs about 210 or and stands at least 5 feet 7.... (I am 5 feet 2 and even pg, was only about 145 or so???)...anywho....

    I get her up and she says "am I supposed to hear FREIGHT TRAINS IN MY EARS????" (!)gulp

    I say, "NO! Let's hustle you back to bed...." TOO LATE...BLAM! she goes down draggin' my pg self w/her. All I could do was SCREAM for help, and a housekeeper nearby (thankfully a strong man), helps get her off me and in bed. She was shocky and her ute was about 2 above her umbilicus and boggy. HOW STUPID COULD I BE?????? If I had ONLY checked the chart and not made my stupid assumptions... ok so what did I learn? Fortunately, after re-establishing IV access, and a 1 liter fluid bolus and vigorous uterine massage, she quickly recovered.

    1. NEVER-- EVER-- take out an IV of a pp patient who has not voided post-delivery. HL or KVO works, but always have access to avoid a MESS LIKE THIS!

    2. Never EVER try to get a BIG LADY like that up ALONE when you are 7 mo pregnant... (duh).... correct body mechanics be damned, you are set up to fail!

    3. KNOW thy patients when you come on and don't ASSume anything.

    GREAT thread!!!
    Last edit by SmilingBluEyes on Jun 9, '02
  5. by   Sleepyeyes
    Originally posted by mattsmom81
    KCL is yellow somewhere? I thought only MVI was yellow...
    Perhaps it's changed, Mattsmom; all I know is back in 1972, in NY, it was yellow, and it was added to my IVF. I was told what it was right then and there, but didn't fully appreciate what had happened until years later....
  6. by   mattsmom81
    I guess I've made LOTS of mistakes but then I've been in this game 25 years. Here's another lesson learned:

    Keep your eyes open and stay alert to situations as we can't always trust that things have been done properly, for example: I was writing admit orders in a new patient's chart my secretary had put together for me. Something didn't seem right and I began to double check things. Sure enough, the secretary had labeled the order sheets with the WRONG patient's name. If I hadn't caught it, there would have been horrendous errors... and all MY my fault as the nurse writing and taking off the order.

    I always listen to that little voice that tells me 'something is not right'....whether it's with a patient, a doc, a chart, what have you.

    Another: Don't ever call a doc with a verbal report of something another nurse has told you....always check the report yourself first.... I received shift report as a new grad: ..'.The patient's throat culture is positive for strep so you need to notify the doc"

    As I made rounds, the patient complained of her 'throat closing up' and was febrile, so I called the resident promptly, telling him of the strep as relayed to me. He came up to asess the patient, and then embarassed me in front of my coworkers by saying scornfully "Don't you know this strain of strep is normal flora in a throat culture?"

    Of course, I turned 6 shades of red and ALWAYS check my results myself now before I start ringing bells and blowing whistles! LOL!


    Another: A particularly bad handwriter on our GI medical staff scribbled something after his order: He had written for "Stomach series EARLY in am....then a few words of gibberish. To me it looked like "notify xray" ie tell them to do it VERY EARLY. The patient was in ICU with lots of lines, drips etc so I ordered it portable...very early. Not an unusual type of request..

    WELLLLL.....this doc chewed my arse left and right...he had written IN dept not TELL Dept...he wanted the films done down in radiology! He reported me for incompetence right up to the CEO (he was that type of doc) Dontcha just love this type??

    I learned to NEVER second guess handwriting.... if I'm not POSITIVELY SURE I get clarification. And if they are chronic bad writers, MAKE them READ their orders to you BEFORE they leave the unit. Warn them if they don't do this they will likely be woke up at 3 am by night shifters doing 24 hr chart checks for clarification.
  7. by   mattsmom81
    I must say I'm disappointed by the lack of responses here. Literally hundreds viewed and added to the thread about 'incompetent coworkers though. Hmmm.

    No wonder we have problems in this profession of ours...when we can't admit to mistakes in order to help one another not to repeat them. It's always easier to point a finger elsewhere for the blame, I guess...or see everyone elses' errors but minimize our own.
  8. by   indeed
    My turn I guess. This was about two months ago...normal night on my unit (telemetry), had everything on earth to do with not nearly enough time to do it. So what I used to do was thoroughly go through all of my monitors during the odd hours and quickly glance at them throughout the night to make sure all was well. What would usually end up happening is that I would have one last really good look at them at around 0500 and then I would be way to busy to go through them that thoroughly again. Well, one morning, I had a typical tele patient, he was in for R/O MI, had been NSR with a first degree AVB all night. I went in to his room to get him ready for an early stress test and got caught up with everything else going on, checked in on him one last time right before shift report, all is well. That night, I come back in and he is still on the unit, so I figured they weren't able to rule him out for an MI. Turns out he never got his stress test...about 10 minutes after my shift ended, he went down to nuclear med. They called up to the floor about a minute after that FREAKING OUT that they couldn't do a stress on this guy because, according to them, he was in a 3rd degree block!! The NP ran down, turns out he was in a really odd 2nd degree that wasn't quite Wenkebach and wasn't quite classical. Even worse though, looking back through the wave review on our monitor (which stores EVERYTHING that monitor has picked up, whether it's normal or not), the day shift nurse saw that he had been in this block since about 0515. This guy was not harmed because of my mistake...his HR stayed WNL and the only reason he didn't get the stress was because the time elapsed before everyone figured out that he wasn't in a complete block. But it's the principle of the thing...scares the shite out of me!!! Needless to say, I have been MUCH MORE thorough when checking my monitors.

    Indeed.

    PS - Somewhat happy ending for this particular patient...he ruled out!
  9. by   RN-PA
    Back in February, there was a great thread entitled "S.O.S" started by a new nurse who was distraught over a med error and many of us responded with our own errors and encouraged her. Here is the link:

    http://allnurses.com/forums/showthre...ghlight=errors

    As I remember the mistakes that I've made over the years, I can say without hesitation that most occurred because I was RUSHING.

    This is what I have learned: I am almost always going to be very busy, but there's a line that can be crossed where one can become like a chicken with its head cut off, and it's DANGEROUS. I have learned to monitor myself when the chaos and demands escalate to that point and I--

    STOP.
    Take a deep breath.
    FOCUS.

    I MUST... NOT... RUSH!!!
  10. by   RN-PA
    Here's the response I gave in the "S.O.S" thread about a more recent med error:

    I made a stupid-- no excuses --med error in the last year involving insulin. The patient was a post-op and I was rushing around during a typically hectic evening. I unfortunately read the patient's insulin order off of the med kardex (rather than from the chart-- I know. I know.) which had been sloppily copied by a Unit Clerk notorious for bad handwriting. (I know. I know. More reason to double-check.) I read "Insulin, 40 units 70/30, SQ q p.m." and administered it after doing a fingerstick to check her blood sugar and after she'd eaten dinner. Problem was, the order was for "Insulin, 4 units 70/30 SQ". On the kardex, it appeared as, "Insulin, 4u 70/30 SQ" with the "u" looking like a "0". .. and I saw "40".

    The House Doctor was called, came up and wrote orders for stat D50 and asked to see the kardex with the order. He said, "What's the problem? It says Insulin 40 units 70/30 here." I showed him the order in the chart and he proceeded to reassure me like crazy that anyone would've read that wrong. The attending M.D. was contacted and also reassured me, "We all make mistakes" and was very kind, but nevertheless, I was beating myself up and deserved any stern rebuke they could've given me; I wrote the incident up, and the poor patient had to endure q1h Accuchecks through the night due to my mistake.

    Yes, I learned a hard lesson that I pray I won't ever repeat, but we are all human and make errors at times. It can be dangerous when things get so chaotic and busy, but it's vitally important to stay focused and calm in the midst of the storm. Some nights I'm amazed that MORE mistakes aren't made... My husband has said, "You can't be perfect-- Nobody is!" But my response is always the same: "This is one job where you pretty much HAVE to be perfect."
  11. by   Cooker93
    I have been a nurse almost 20 years now and I've only made a few errors, that I actually caught and am for sure about. They were big enough, that I learned from them and haven't repeated them(I hope). I had just gotten my license to work and it was my FIRST 3-11 shift by myself. The order said Give Phenobarb 10mg. 3 tabs.- So I did, only the pharmacy changed meds and they were 30mg tabs now-I gave 3. Had to call the Doc. He was very nice and said the pt. will probably get a good night's sleep-probably be the best they've had in a long time. I check meds & orders very carefully now. I even check so careful, that I find med errors all the time-I recently had an order for Protuss-D for a resident with a bad cold. When I got the card from the cart, the label said Posture-D. Never heard of it, so I called the pharmacy and sure enough it was calcium with vitamin D-not recommended for cold symptoms. I had to call the Dr. and fill out the med error report because about 7 of the pills had been given and I found the med error. That sucks. Then a week ago, a newly hired nurse & I were counting narcotics at the end of her shift and the off going nurse said there should be 35 Ativan. There were 37. She said she gave them and the count was wrong. She had 38 @ 6am and they were to be given @ 8, 12 & 4. We counted @ 10pm. I guess she didn't give them all, huh??? She argued with me for a long time on that one. Also, those were #6 & #7 med errors I had found on her since she was hired about 18 days earlier. She's a MAJOR accident waiting to happen.
  12. by   Cooker93
    When I was a nursing student, a Doc wrote an order for "40 Units Insulin." The nurse didn't question it, the pharmacy didn't either & sent up Regular insulin and the day nurse gave it before breakfast was on the floor. I took the woman bkfst. Needless to say, she was almost comatose. I got the charge nurse for the floor, she started a glucose IV and I poured sugar under her tongue. The woman finally aroused, but it was touch & go for awhile. I learned it's better to not give the insulin, check the order and make sure the food is being served before insulin is administered-especially Regular. The new Humalog works even faster than Regular. I have to have the tray in front of the resident before I give it.
  13. by   deespoohbear
    We get a lot of patients in for outpatient blood therapy. We transfuse them a couple of units and send them home. The order was for Benadryl 25 mg IVP before the first unit of PRBC's infused. I was in a hurry and didn't double check the order. The pharmacy sent po Benadryl and I gave it. After a few minutes I realized what I had done and called the doctor. He was very nice about it and said the po would probably last longer than the IV. Haven't made that mistake again.

    I have also given the wrong meds to two little old ladies. (They all look alike after awhile, don't they?) As soon as the second old lady took the meds I realized what I had done. My heart dropped all the way to my feet. The doctors were pretty cool about it, but I was sick for 2 days afterwords.

    Another thing I have learned over the years, is SIGN immediately after you give a medication. I was covering some patients for one of my co-workers while she was at lunch. The post-op patient was complaining of severe pain. I checked the MARS and saw that nothing had been given. I got the Demerol that was ordered and went and administered the prescribed dose. Not long after that the patient's nurse came back to the floor. I told her I gave the patient Demerol. She got this blank look on her face and said that she had given the patient some Demerol right before she left for lunch. She started getting on my case for giving it, and my response was to sign the stinkin' MARS for crying out loud. I can't read minds!! So, now if one of my co-workers is leaving the floor I always double check with them about meds. If it is not signed off, I page their nurse and ask. BTW, the patient was not harmed.

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