What's the biggest mistake you've ever made as a nurse? What did you learn from it? - page 5

by Mini-Murse

87,370 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


  1. 1
    You'd be surprised at some of the things new nurses come out of school and have never done.

    My advise is , whenever in clinicals, be sure nurses know you want to at least watch anything interesting even if you can't talk your instructor into letting you do it.
    tyvin likes this.
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    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 graduated 15 years ago, and the first IV and the first Foley I ever did were in my preceptorship. So, I hadn't graduated yet, but I didn't get to do them in clinicals. I have acted as a preceptor for nursing students for the last 4 years, and most of my students had many "firsts" while they were with me. I expected that, and made it my goal that by the time they left me (and graduated) they would be proficient in Foleys, IVs, and straight caths.
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    My worst error was actually averted at the last minute (thank you, God). Back when I was a new nurse, we had multidose vials of Potassium on the unit. Our drug cart had a little indentation meant to hold a multidose vial of Normal Saline for flushes. Both medications had a navy blue label. I had a very busy night with moms and babies, and I had 3 saline locks to flush before my shift was over. I pulled up 3 syringes of 3cc of what I thought was normal saline, and headed down the hall. I heard an audible voice say, "Stop, go back, and look at what you did." I did as commanded, and found that I had drawn up 3 syringes of KCl. I threw the syringes in the sharps container, threw the KCl in the garbage, and went in the breakroom for about 15 minutes of absolute hysteria. I then called my nurse manager who handled it very well, she patted me down and convinced me that I didn't need to immdediately resign.

    I learned some valuable lessons. Always, always double check medicines. And people can do really stupid things--who puts a multidose vial of potassium in a slot intended for normal saline?! I was thrilled when we no longer mixed our own potassium, as I had lived out how easy it would be to make a mistake.
  4. 0
    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!!
    Ah, thats sad your preceptor was mad. I just recently started precepting and my orientee made a med error (gave 650 mg tylenol and 2x 5-500 lortab togehter which both contain tylenol.) I wasn't upset, it is more like....What did you learn from this? we wrote up a med event together, called the doc. The patient was totally fine.
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    I worked at an allergy clinic and had a pt on the highest concentration of his allergy shot serum. He was still in the build-up phase (where they start at 0.05 and titrate up to 0.5 ml). I gave 0.5 ml and pt sat for the required 30 minute wait. A few minutes later another nurse shows me the chart and asked if I gave the dose I wrote down, and that's when I saw the error--I gave 0.5 when the previous dose had been 0.05 and I should have given 0.075. Pt was starting to have an anaphylactic reaction and was being given epi and xopenex nebulizer treatments while being monitored. I apologized to pt and parent (it was a minor child). Pt was okay and stayed for observation an hour and was late being taken to school so pt missed the class field trip that day.
    I learned to triple-check EVERYTHING and look back at the past few doses, not just one, and if I can't decipher the handwriting, ask the person who wrote it. We wound up going to an electronic injection record to cut down on trying to determine if it said 0.5 or 0.05 and all agreed to stop using the leading zero.
  6. 0
    Quote from monkeybug
    My worst error was actually averted at the last minute (thank you, God). Back when I was a new nurse, we had multidose vials of Potassium on the unit. Our drug cart had a little indentation meant to hold a multidose vial of Normal Saline for flushes. Both medications had a navy blue label. I had a very busy night with moms and babies, and I had 3 saline locks to flush before my shift was over. I pulled up 3 syringes of 3cc of what I thought was normal saline, and headed down the hall. I heard an audible voice say, "Stop, go back, and look at what you did." I did as commanded, and found that I had drawn up 3 syringes of KCl. I threw the syringes in the sharps container, threw the KCl in the garbage, and went in the breakroom for about 15 minutes of absolute hysteria. I then called my nurse manager who handled it very well, she patted me down and convinced me that I didn't need to immdediately resign.

    I learned some valuable lessons. Always, always double check medicines. And people can do really stupid things--who puts a multidose vial of potassium in a slot intended for normal saline?! I was thrilled when we no longer mixed our own potassium, as I had lived out how easy it would be to make a mistake.
    I'm guessing that mistakes like these were so common that hospitals just started carrying pre-mixed saline flushes to prevent them. Thank goodness your Guardian Angel Nurse was watching over you that day! I hope that when I get around to making my first med error (which I know will happen, I'm human after all!), my G.A.N. will also be watching over me like yours was!
  7. 3
    Quote from monkeybug
    I heard an audible voice
    ''

    Inside your head or outside of your head?
    ama3t, catebsn25, and DawnJ like this.
  8. 2
    Excellent topic.

    Lessee.....very early on, in my first months as a nurse, I misread a MAR when I was doing the 24-hour night check (where you reconcile the previous day's MAR with the one printed for the next day, comparing to orders). Somehow I did SOMETHING that would have resulted in a patient getting something like 50 units too much of Lantus! The nurse who had the patient the next day caught the error--BEFORE she gave it, thank heaven--and the NM pointed it out to me when I came in that evening. Scared me to death that it could have been given because of something I did. NEVER did anything like that again, I assure you!


    Hmm....I once gave a full tab of Lopressor 25mg instead of a half....which would have been 12.5mg....figured it out an hour later, panicked and did BP checks, did several more that night! He was fine What did I learn? That it's STUPID to order a drug that way. Urgh.

    And finally....How about hanging the exact same IV atx 3 hours after the last--when it was supposed to be given q6---because I grabbed the wrong one? Was supposed to give two, alternating....oops. I did notify the MD, who didn't think it a big deal, so.....note was made, no one died...this was also in my first year of nursing.....and I learned to READ much more carefully!

    Not sure if this post makes me feel like a crappy nurse for making these errors in the first place, or a good one because I've never done anything like them again
    calivianya and Armygirl7 like this.
  9. 12
    Quote from brillohead
    I hope that when I get around to making my first med error (which I know will happen, I'm human after all!), ...
    Oh, no doubt. I once had an instructor tell me that if any nurse with any amount of experience tells you she/he has never made a med error they are either lying or are too stupid to know the difference.

    Loved that instructor.
  10. 0
    Quote from monkeybug
    My worst error was actually averted at the last minute (thank you, God). Back when I was a new nurse, we had multidose vials of Potassium on the unit. Our drug cart had a little indentation meant to hold a multidose vial of Normal Saline for flushes. Both medications had a navy blue label. I had a very busy night with moms and babies, and I had 3 saline locks to flush before my shift was over. I pulled up 3 syringes of 3cc of what I thought was normal saline, and headed down the hall. I heard an audible voice say, "Stop, go back, and look at what you did." I did as commanded, and found that I had drawn up 3 syringes of KCl. I threw the syringes in the sharps container, threw the KCl in the garbage, and went in the breakroom for about 15 minutes of absolute hysteria. I then called my nurse manager who handled it very well, she patted me down and convinced me that I didn't need to immdediately resign.

    I learned some valuable lessons. Always, always double check medicines. And people can do really stupid things--who puts a multidose vial of potassium in a slot intended for normal saline?! I was thrilled when we no longer mixed our own potassium, as I had lived out how easy it would be to make a mistake.
    That is truly scary. It reminds me of an error that we discovered once at my LTC job. A narcotic discrepancy led to our discovery that a patient has received several doses of subQ injection of heparin (which was not prescribed for her) instead of the intended Dilaudid injection. Someone had put the bag of heparin vials in the narcotic drawer, and both were same-colored vials.

    I myself made a similar error of not reading the label, and gave Ativan instead of Dilaudid, same white round pill of similar size. Being in a rush inevitably introduces all kinds of stupid stupid mistakes.


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