Nursing errors I learned from...

  1. 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 we learned from those mistakes?

    Let's make this thread a positive one and hopefully we will help each other avoid the same errors in the future....

    Here's one of many of mine...I will add more as we go:

    I got hoodwinked into staying over and doing a double. I was exhausted with a sick baby at home and had not slept well in a week. I was like a zombie making that last med pass at 6 am..and I had 13 patients on medsurg to pass meds to.

    Well, we were short (and this was 20 years ago...not much different now is there?) and I was behind so I cut corners...found out later I had completely mixed up two patients' medications.: patient A got patient B's meds and vice versa.

    Well, luckily these ladies were astute enough to not take them. I wish they had said something to me at the time, but as I said, I was rushed and behind so I probably didn't give them a chance...just pushed the pills at them and ran off....

    My director called me at home later very sternly..to come in for a counseling. I felt awful. The ladies, of course, had spoken directly to my boss about this mistake I had made. No harm done, Thank God, as the patients didn't take those incorrect meds I gave them.

    I learned not to let myself get talked into working extra when I know I'm already exhausted. Saying 'No' is the safest thing to do in those circumstances, to avoid potentially serious errors due to exhaustion.. And I also learned never to shortcut the '5 Rights' of medication administration because I am 'running behind.'

    Anyone else ready to 'fess up'? :imbar
    Last edit by mattsmom81 on Jun 8, '02
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  2. 51 Comments

  3. by   AmandaDawn
    I have had a few. I've been Nsg for 2 yrs now and I started off a brand new nurse with no experience. I started working in a nsg home that I had done clinicals it. Well Some pts had armbands and some didn't. Probably nore didn't than did. Well I ask a nurse who a pt was and she pointed to her...or so I thought she did. Well I ended up giving...I think it was a sort of vitamin to the wrong pt. Now things I have seen others do wrong that is numerous. Say a woman chart that a foley was drining Clr yellow urine at one time and I checked 45 mins later and the pt had sediment in the tubing and hadn't been draining for a while. I remove the foley and she soaked her bed. It really gets me thta some people do stuff like that. But I guess that becuz I care. And there are so many that are in this profession for the wrong reasons and don't care a bit. I also had another incident where we had a Dr that you were not allow to hold his meds no matter what. So my pt had Lantus Insulin order. His Accucheck was 70ish so I didn't wanna give him the lantus esp since I knew he had frequently dropped in the 40's and lower. I went to my charge nurse and told her and she said of that is Dr ___ Pt and he never wants us to hold any of his meds. I felt iffy but charted excatly what my charge nurse said and I gave the med. I kept an eye on him and it was getting late and he went to sleep. I was still iffy about the whole thing and things struck me as wrong whe I went to check on him so I tried to wake him up. He didn't wake. His bs was in the teens. They did the push meds and got his BS back up to 60ish but he never aroused. We shipped him to the ER. TO this day I don't know if he lived or not. But what I learned from this is if you don't feel comfortable doing something...we as nurse have the right to refuse to do it. I'm a young nurse so things are hard for me sometimes and I feel like I should listen to the charge nurse becuz she knows better. I have learned this is not always true and I now have no problem refusing to do something I'm not comfortable with.

    **These experiences are why I made the Signature quote I have. I truely believe it!
    Last edit by AmandaDawn on Jun 7, '02
  4. by   zumalong
    When I was a new grad (way back when) I was also in a hurry. I had been working on the unit for about 6 months. I had to give a digoxin to the patient. I did not follow my 5 rights and accidentally gave the patient in the A bed the B bed's dig.

    I still to this day--17 years later--remember that feeling of eating my heart. I immediately let my DON know, called the Dr. and filled out the med variance report. I can remember my DON telling me it was ok (I was of course crying) and the doc told me to monitor his pulse q15 min for 2 hours. I was also shocked that I did not have to let patient know. (I was actually encouraged to not tell him). He did not have any adverse effects for the rest of my shift. I remember calling the floor at 2am because I wanted to see if he was still alive. He was.

    I learned that no matter how busy I was, I needed to follow the five rights. I also take my med kardex into patient room to double check. Right after this incident we had a new RN give K+ IVP and the man died as a result of cardiac arrythmias. It was awful. I think these two incidents really hit home with me and have remained the motivation to be careful with meds.

    THe other potential mistake was not even a mistake, but I was sure I had killed this patient. We had all been certified in IV starts (back in the '80's when hosp had these things called IV teams). I started my first IV after my 10 supervised sticks, I went through the vein when I was advancing catheter. I pulled it out and noticed it was slightly bent and shorter than it was when I placed it. My mind began to imagine the piece of catheter floating around the circulatory system. In a matter of 5 sec I had this 23 year old dead of an embolism in her heart, lung, or brain. I again started to eat my heart--I finally figured out that none of the catheter had broken off--the needle had made it appear longer when I placed it.:imbar Thank goodness I realized this in the space of 2-3 minutes or I might have had an MI.

    I am sure there are more--this is a good idea for a thread.
  5. by   mattsmom81
    OK, guys, I KNOW there are more nursing mistakes out there than this....as we are ALL human...... Come on, be brave and help out younger nurses...admit the mistakes you made and what you learned!!!!

    Here's another of mine:

    I was a new nurse in ICU and I was taking shift report from the offgoing nurse. The last thing he said to me was "Oh I called the cardiologist and he just called me back, I haven't written the order yet but he said to hang Dopamine at 5 mcgs" Well, this made some sense to me as the BP was borderline low, so I went
    and hung the Dopamine, then got report on my other patient.

    After an hour or so my other patient's doc hunted me down, he happened to make a second set of round. He screamed at me " What the *XX## is Dopamine doing hanging on my patient?" With a heavy heart, I went to the chart, and sure enough, the previous nurse had written an order...but to hang DOBUTREX not Dopamine.

    What did I learn? ALWAYS take shift report in ICU with the chart RIGHT IN FRONT of both nurses, and ALWAYS check the written order, do NOT take another nurses word alone without double checking the chart and/or MAR. Obviously, the day nurse had a 'brain fart' and SAID 'Dopamine' instead of 'Dobutrex' to me, BUT I MADE THE ERROR and got in trouble for it.

    OK, guys, I'm waiting to see more...:kiss
    Last edit by mattsmom81 on Jun 8, '02
  6. by   coleen
    I was a nursing student on my clinicals and there was this lady in a hoarse voice whispering water please, water please over and over and over and she looked so damn dehydrated. It crossed my mind that she might be NPO but there was this container of water at her bedside so I guess she could drink. I poured a little water in her mouth - she gasped and coughed and aspirated and then I realized I had given her the nasal suction box contents. I did not tell!

    I also am new to long term care having worked in an urgent care clinic for 4 yrs - so the resident would not take her meds - every day every day and she was on an antibiotic and the nurses would just circle initials and write refused. Well she was my husband's grandma and I was going to do all it took - She looked up and said I don't trust any of you but I'll take it if He gives it to me - It was the janitor helping pick up bibs in dining room. I held the spoon and he "helped" push it in and she took her meds - the next day I got in very very big trouble because Lyle the Janitor was in the breakroom bragging about his new job as "med passer" and my DON found it quite interesting. I SWEAR i didn't know! It was written on report since when did Lyle get his license?
  7. by   jevans
    OK I'LL BE BRAVE

    Iwasn't a junior nurse or a student, I had been qualified for 15yrs.

    It was a typical busy shift in acute medicine, understaffed and overstretched. I was the only qualified for 19pts with an unqualified and a student. I had 5 emergency admissions!!!!A new patient needed IV Fluids I got the bag ,attatched the giving set, all the while reassuring this patient. When a student came to me and asked me to review a patient she was concerned about. I left what I was doing to check out her patient. This patient had chest pain, so did an ECG confirmed acute changes called DR Drew up Diamorph and maxalon.
    REMEMBERED- that I hadn't conected the IV so asked the student to monitor pt with chest pain until DRS arrived and went to conect the IV. I attatched the giving set to the cannula, started the IV. GOT CALLED as chest pain pt deteriorating. Spent the next 20 mins preping pt for CCU.

    Checked the IV pt noticed that it wasn't infusing, then needed to take pt to CCU. Nurse practioner came on to ward and I asked him to check the infusion cos it wasn't working while I escorted pt to CCU.

    When I got back! I found that the reason the infusion was not working was THAT I HAD FAILED TO RUN IT THROUGH THE GIVING SET :imbar I was mortified. I could have caused serious harm. Luckily no harm was caused.

    Lessons learned-

    1) Always acknowledge to senoirs that a situation is risky

    2) Ask for help!!!!!!!!

    3) Do not start a job without completing it

    4) Always remember that old age pensioners like me are not invinsible. Errors can happen to us all

    I openly discussed this incident with other colleagues in the hope that they learn from my mistakes

    Development involves sharing
    LOL
    j
  8. by   WashYaHands
    As a new grad, probably 6 months out of school I was passing meds to my patients. I was at my med cart preparing meds for patient A when a PT approached me and asked me a question about another patients meds. I flipped the MAR to patient B's record. After the PT left I ended up giving patient B patient A's meds. I returned to the MAR and realized my mistake. My heart almost stopped. I paged the physician who was in the hospital, told him what I had done. We both looked at the MAR to see what I had given patient B, and he assured me that nothing I had given her would hurt her. He sensed my anxiety and the fact that I was on the verge of tears and called me a "med error virgin". I wrote an incident report on myself for my error. I learned a valuable lesson in that I am now very meticulous when passing meds and politely ask people not to distract me.

    Linda
  9. by   RNinICU
    Giving meds to the wrong patient seems to be a common error. I did it once, when I was fairly new, and spent half an hour in the bathroom throwing up. I thought that I had probably killed the patient. The other nurses and even the doc thought it was no big deal, and the patient came to no harm, but I still make sure I double check the patient's ID every time I give a med.

    Another dumb thing I did was to hang blood, set the pump and turn it on, but I forgot to connect it to the patient and ran about 50 ccs all over the floor.

    When we still used ice with our cardiac outputs, I was getting outputs much higher than the previous shift. Then I discovered that I had not connected the temperature probe to the syringe to read the injectate temperature.

    I have also run tube feedings into the bed, and given the wrong labs to a doctor. We all make mistakes, sometimes because we are rushed, sometimes because we are distracted, and sometimes because we are just not paying attention. Fortunately, most mistakes do not cause any harm to the patient. However, we must all strive to be more careful when giving meds, or doing any procedure on a patient.
  10. by   Teshiee
    One night when I was working in LTC. I gave insulin to a non diabetic patient I was mortified I checked that patient's blood sugar every hour thank goodness it wasn't a lot but it could have been worse. Like with all you said when I am giving meds I do not want to be disturbed, I want an arm band on. I recheck the med sheet again if I am not sure. Scary isn't it.
  11. by   AmandaDawn
    U know tho...I have a question and I hope people will be honest about it. Has anyone ever not reported med errors or other errors they have made on the job after you realize there is really no way that the mistake will harm the pt? Like giving the wrong pt a Vitamin or something.
  12. by   RNinICU
    Always report a med error, even if it is minor and you think it won't harm the patient. First of all, you don't know what harm the med might possibly cause, or how it may interact with other meds. And second, integrity is an important part of being a professional. One should never put self interest above honesty and patient safety.
    Last edit by RNinICU on Jun 8, '02
  13. by   amdrn
    Hey all, here's a baddie. I had been an LPN for 21yrs. and decided to go get my RN. Everyone told me I should be an RN and I believed them.
    Anyway, I had been out of school for about 6 months, cocky as hell as I had all this experience?!?! My unit was short and they asked me to work 11-7 after working 3-11. i wanted to make a good impression at my new job so I agreed. About 6am I had to hang a new IV bag of NSS. I went to the bin marked NSS and grabbed a bag, without checking it I hung it. My charge nurse called me at home telling me I hung NSS with 40meqKcl. Of course I said, no way, I got it out of the right bin..
    Thank the dear Lord it was not a renal or cardiac pt and he was ok. I can say, it sure put me in my place. Following 5R's is so important.
    I can tell you that I check, check and double check all meds, IV's, treatments etc.....
    The incident also taught me I'm not invincible. I can make a mistake. Sure put me in check. Just thank God a patient didn't have to suffer at the hands of my ego. I must say, I am much more humble now.
  14. by   coleen
    I agree - always report med errors!!! I have made a couple of doozies but then I was able to get dr.'s advice on resolving or monitoring the potential problem. Even a vitamin would with my luck be the one thing someone is really allergic too or cannot take due to other conditions. I never get in trouble when I report the error - not reporting is really grounds for license reovokation

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