What's the biggest mistake you've ever made as a nurse? What did you learn from it? - page 4

by Mini-Murse

68,743 Visits | 139 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


  1. 0
    Quote from RNewbie
    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.
    I just posted a response to this above, sorry!
  2. 3
    I accidentally attached Pitocin instead of LR directly to the hub of a triple codon and opened it wide; the lines were clearly labeled, I was just chatting with mom and not paying attention. The patient may have gotten, at max, 2 cc's before I caught the mistake. The patient had a 10 minute tetanic contraction. I put mom on a mask and stayed at bedside. Thankfully the baby's heart rate stayed stable and mom was ok. I explained exactly what happened and mom revealed she is a RN in a neighboring city. She and I ended up turning it into a learning opportunity. She was amazing but I still have not recovered! The midwife, unit director, and charge nurse were all amazing actually. My mistake caused a change in line label sizes and colors to draw more attention to high risk drugs.
    Call me sparky, AnonRNC, and Armygirl7 like this.
  3. 0
    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?
    I just found out that we are not allowed to start an IV at any of our clinical sites (I think because of insurance reasons). We do have to know the mechanisms of how to do it, but the only practice we get is in lab next week on a fake arm that bleeds. I think it's a little crazy that we won't be able to start on IV on a real person until we are licensed RNs.
  4. 0
    I made two med errors, neither too damaging. I gave full 25mg tab of Metoprolol instead of half 12.5mg tab. I also gave Ativan instead of Oxycodone. Both patients were fine, just a little sleepy for the second.

    We did not do IV starts in school. I learned as part of a program in my hospital. We also do not do double checks for insulin (except IV) although we do them for other high-alert meds.
  5. 2
    For some reason this one really sticks out in my mind (although I know that I've made others)!...

    My patient needed lab work and was an extremely difficult stick-we could only use her feet and they had already been stuck multiple times (some had been unsuccessful). As fate would have it, she was a post-op patient and had rapidly started to go downhill. Around the time that this was happening, the charge nurse was able to draw her blood. I was so shaken by the patient's status change and rattled from a nasty debate with the resident about whether the patient's condition was as serious as I believed it was that I sent ALL FOUR TUBES OF BLOOD to lab UNLABELED!! Argggghhhh!

    Of course this meant that the lab couldn't take them and the stat blood work that was instantly ordered (when the ATTENDING finally convinced the resident that the case needed attention) couldn't just be added on to previously sent blood. I was sooo embarrassed to have to spill the beans to the patient and the charge nurse (who was awesome enough to miraculously draw more blood for me!) - not to mention give the MD a heads up about why the labs wouldn't be available as soon as they thought they would be.

    Sooo, I learned to ALWAYS label your blood/reqs correctly and follow the same routine with them EVERY TIME!
    calivianya and RNperdiem like this.
  6. 0
    On my first job as a nurse in LTC I had a 30 pts on a sunday and was doing a discharge. I correctly wrote the meds, dosages, and directions on the discharge sheet and double checked it was correct. We sent pt's home with 3 days meds in freaking labled ziploc baggies. well of course we were 3 short so my manager told me to double up on the meds to each bag and put two labels on the bag. I put lasix and another medication in the bag. The one med was 4x/day and the lasix was only one. But I labled them both as 4x/day. So the pt took 4 lasix the next day because he was going off the baggies instead of the discharge papers and he ended up in the ER. He was fine thank the lord! But I was terrified and felt sick for doing harm to this pt. I learned to triple check everything and not to listen to that manager who had me double up on bags. I felt nervous doing it and I learned to go with my intuition. I was wrote up and put on a probation of sorts for 30 days which I completed fine but I left shortly after.
  7. 3
    Recommending we withdraw care on a patient we flogged for about 2 mos, weeping edema, poor cardiac output, exuding odor from browned extremities, infections in every invasive site. We were on the fence, communicating with family but I had enough. Several of us were pushing with ethics and Dr's to call it and withdraw care.

    This very man returned, walking into our unit bringing all of the staff a nice lunch tray 6 months later, thanking us for saving his life and never giving up. I quietly slipped off to the bathroom and doubled over, gagging. I couldn't eat! I couldn't believe what just happened. I felt so undeserved of the very air he was breathing. I felt incredibly small.
    Last edit by CASTLEGATES on Oct 14, '12
    kiszi, canoehead, and lalopop86 like this.
  8. 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?
    We did a lab day on it, and we can do them in clinical (Med-Surg III) if our clinical instructor is with us or has signed off on us performing it with just a floor RN with us. However, we were told back at the beginning of the program that the local hospitals have told the nursing program, "We can teach them to put in IVs, what we can't do is teach them to think -- you send us grads who can think, we can teach them to insert IVs here on the job."
    1pinknurse likes this.
  9. 3
    I'm not saying and yes I learned from it.
    nyteshade, RNperdiem, and Despareux like this.
  10. 0
    Quote from tokmom
    I'm not saying and yes I learned from it.
    Smart!


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