What's the biggest mistake you've ever made as a nurse? What did you learn from it? - page 3

by Mini-Murse 90,120 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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    When I was a brand new nurse and still w/ a preceptor, I misread a MAR and gave 25 units of regular insulin instead of the ordered 25 units of long-acting insulin. My preceptor was mad, I called the doctor and had to give the pt a dextrose IV and do hourly finger sticks. I was pretty embarrassed but I think my preceptor could have been a little more involved, she was in space that day!!! Since then, I always triple check insulin dosing!!
  2. 1
    Quote from cn2007rn
    When I was a brand new nurse and still w/ a preceptor, I misread a MAR and gave 25 units of regular insulin instead of the ordered 25 units of long-acting insulin. My preceptor was mad, I called the doctor and had to give the pt a dextrose IV and do hourly finger sticks. I was pretty embarrassed but I think my preceptor could have been a little more involved, she was in space that day!!! Since then, I always triple check insulin dosing!!
    Just wondering if your facility has a policy that insulin and other high alert meds have to be verified by 2 nurses? I had a near miss with insulin one time. It was night shift and I was going to give sliding scale insulin based on the day time scale. When checking it with another nurse it was brought to my attention that the pt was not suppose to get any insulin based on the night sliding scale. Mistakes are so easy to make. I usually triple check my meds but somehow in this case I was reading the MAR wrong, didn't scroll down far enough to see that there was another sliding scale below the daytime one.
    ARTPOPIST likes this.
  3. 7
    Thank you so much for this topic. It reminds me that I am not alone & none of us are perfect (especially the one's who can't admit it).
    Kissy1818, smartypantsnurse, ICUman, and 4 others like this.
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    I will never forget my first med error. I was caring for a mom in labor with her 3rd baby. GBS positive. I gave penicillin, even though it was BRIGHT red on her chart, labeled everywhere that she was allergic. Thank god, she was absolutely fine with no reaction. It scared the bananas out of me.

    This isn't a med error per se, but I gave a kid a water bolus through his gtube with the extension clamped and the med port open. Water everywhere, all over his freshly changed clothes, the linens etc. I gave like 50cc before I noticed what was going on.
    smartypantsnurse likes this.
  5. 0
    Calinurse,

    If it makes you feel less panicky and scared about your daughter's egg allergy, I was allergic or intolerant to
    so many foods as a baby, that I was tested early. I repeatedly tested positive for an egg allergy (and still do!)
    so my mom didn't give them to me in any shape or form.

    When I was about three and a half, the babysitter fell through and my uncle and his brand new wife volunteered to keep me overnight and bring me back in the morning. They, together, knew virtually nothing
    about little kids and somehow, my egg allergy was forgotten.

    We had scrambled eggs and pancakes for breakfast and I mentioned later how good breakfast had been, to my
    mom. When she called the pedi, she said either it was a very very mild allergy or a false positive.

    Decades later, I still test positive to eggs, but eat them with no problems whatever. I'm not trying to give medical advice. I'm just saying don't give up hope, since she didn't react to the shot.
  6. 0
    My biggest mistake was a med errror on a pediatric pt. I had recently been transferred to the ED after working for a couple of years on a stepdown unit and while the rest of the hospital uses metric system, the ED uses standard. Still being in the mindset of my former unit, I thought the triage nurse meant 20 kilos and did the mental conversion in my mind from kilos to pounds and entered the information. So when I admitted the pt, I started her antibiotics right before she was to go to the floor. Unfortunately, the pharmacy was dosing her at 44lbs and this wasn't caught until the pt arrived on Pediatrics. Thank goodness for pediatric nurses. The antibiotics were not enough to hurt the pt but the potential for damage is there. Now I double and triple check everything on peds patients.
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    im still on orientation on a med/surg unit. just a couple days ago, i went into a pts room to put up a new bag of fluids. she was sleeping, so i didnt want to wake her and look at her IV site, so i just quietly hung the new bag and walked out. i even charted that her IV site was wnl, dressing dry and intact. an hour later she rings her bell and says her arm hurts and its all wet. The site was infiltrated. it was so swollen and red, i felt so bad. it didnt seem to bother her that much, she said she thought it was kind of interesting. hah. i pulled her IV, elevated her arm and had another nurse start a new one (because i havent started an IV yet and I didnt want to cause the poor girl any more pain via me attempting to wiggle a sharp needle into her arm not knowing what i was doing.) ive learned assessing IV sites is pretty important from now on!
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    You're a new nurse and have never done an IV stick? That scares me a little bit... I'm in my RN program now and would be terrified if I found out we wont get some exposure to that! Then again, maybe I won't? Has this happened to many others?
    Anna S, RN and BuckyBadgerRN like this.
  9. 1
    Quote from aachavez
    You're a new nurse and have never done an IV stick? That scares me a little bit... I'm in my RN program now and would be terrified if I found out we wont get some exposure to that! Then again, maybe I won't? Has this happened to many others?
    Most programs do not teach this anymore. Something they say you will either learn on the job or have an IV team to do. We learned it in my program but only got to practice on a fake arm.
    Not_A_Hat_Person likes this.
  10. 0
    This was a few years ago and it was a paper MAR, they had the Lantus and regular insulin listed right in a row and I got mixed up, no policy that I know of but I left that hospital. The hospital that I worked at more recently does have high alert meds highlighted and some of those meds needed 2 nurses to sign off so it could be give.


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