What's the biggest mistake you've ever made as a nurse? What did you learn from it? - page 2

by Mini-Murse 90,271 Views | 154 Comments

If you feel comfortable posting to this thread, awesome. If not, no biggy! I was wondering what the biggest mistake you've ever made in your nursing career has been. It could have to do with drug dosage or administration, or... Read More


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    I think I would be scared to be on a locked pysch ward with any patient. When I was working at a nursing home we had to lock doors behind us and I think that always put me off mental health nursing although I don't have any trouble with dementia patients. The mistake I worrry about was one where I warmed a heat pack for an aged lady in pain and didn't heat it for all the required time. I placed it in a pillow case and lay it over the patient's nightie and dressing gown to make sure it wasn't too hot. After five minutes, I approached the lady and asked if the heat pack had helped. I was told everything was perfect. I went to break and was shown a red mark on the patient's back when I got back. I apologised and admitted to giving the lady the heat pack and went to fill in an incident report. I was told I should have heated it in 20 second bursts. The pack didn't say that, just to heat for three minutes. Talk about feeling like an idiot. I learnt something though, just be very careful who you trust, one might
    give you a recommendation while another two are trying to make mischief.
    pinkchris2000 and sharpeimom like this.
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    I was giving multiple chemotherapy meds to a 2 year old for her ALL, mixed syringes up, and mistakenly gave a hep flush IM (was supposed to give L-Asparaginase). I was fortunate that I had already given the Vincristine IVP and not mixed up THAT syringe.

    I was just on the receiving end of a major med error last week. I am on Tacrolimus for a kidney transplant and had a recent foot infection leading to Orthopedic surgery. My foot ulcer grew out an opportunistic Candida, and after consulting with ID, the Ortho PA rx'd Fluconazole. When I had my monthly labs done, I was in acute renal failure and Tacrolimus toxicity. The PA surely had a warning of a major interaction between Flucoazole and Tacrolimus, but apparently ignored it, and never consulted with the Transplant doc who manages my Tacrolimus.
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    A patient was allergic to the skin cleaning prep wipes we use and I neglected to tell the nurse coming on. The patient needed blood and an IV was started by another nurse--using the wipes. Thank goodness there was no reaction. There was a sign in the room about it and an allergy band on and a note in the chart...but it's super rare to be allergic to these wipes and had I been in that nurse's shoes, I can't say for sure that I wouldn't have caught the mistake.

    Felt so horrible about it...especially because I wasn't the one reprimanded about it. Technically, yes I wasn't the one who did the actual error, but it really was my responsibility to tell that nurse, especially since it's so rare. I apologized to the nurse profusely.

    CHECK YOUR ALLERGIES!
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    Early in one of my first clinicals I was removing tape from a patient's arm. I was unfamiliar with the appearance or fragility of "prednisone" skin. I caused an ugly skin tear when I removed the tape too quickly. I wanted to quit right there and then.
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    I once gave an injection, back when I was still intimidated by older nurses and Doctors, And I was told to give a Morphine injection, when I went to check the chart for myself for drug allergies, I was barked at by the Doctors. I foolishly followed orders, and yes- the patient was alergic to Morphine.

    I never, NEVER made that mistake again. I lost my bashfulness immediatly.
    The patient was alright, thank God.
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    I didn't realize as a new grad just how much doctors DONT check allergies. In the ER, they throw around orders and dont think twice about it. On several, several occations I have already gotten the meds and thank goodness I asked allergies.

    Nothing is more terrible than that sinking feeling after you realize you've made a med error. Even a "small" one. Ugh. Makes me sick just to think about it!
    calivianya and ohioSICUrn like this.
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    Becoming a nurse was the worst mistake of my life!!!! I get verbally abused every day by either coworkers,patients or family of. Sick of it. Sould have went into interior design.....
    Kissy1818, Anna S, RN, ICUman, and 5 others like this.
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    Worst mistake..... Putting a demerol syringe in the pca instead of the morphine that was ordered when I changed it. Thank god he wasn't allergic, it he was getting the wrong drug and highly undermedicated. The doc caught it, was a cool doc, and we wrote an incident report.From then on I look up brand names, rather than generics ( too much alike) and don't rush and quadruple check!
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    Great topic!
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    My first error was for a patient that was on two syringes of antibiotics every 4 hours. For my entire shift I gave only one syringe per dose:/

    I also crushed medication that said non crushable, I asked the doc who was there if he wanted to change the medication, and he said to just crush it. I learned later that pharmacy had a crushable version that I should have called and ordered.

    My daughter has been on the receiving end of medication mistakes, once we were in the doctors office getting her allergy results. The doctor came in and explained she was allergic to eggs, milk, cheese and a multitude of other things, then said "you want to get her flu shot today while youre here?" I said sure (this was prenursing, had no clue the egg-allergy reaction from the flu shot). So she got the flu shot and had a major skin reaction that caused her throat/tongue to swell as well as hives all over her entire body.

    The she had to have a medication called albenza, the doctor knows her allergies and still prescribed it (it has an egg allergy alert also) and they also dosed her with an adult dose (over 4 times the max amount for her weight)....again major allergic reaction. Needless to say I got a different pediatrician that day. This was also pre-nursing. Now that I know a little about medication and dosages I meticulously check everything I give to her everytime. Dont blindly think these doctors always get the doses right!!


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