What's the biggest mistake you've ever made as a nurse? What did you learn from it? - page 6

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. 3
    I was working in long term care on night shift and one of the residents had just been started on an antibiotic for cellulitus. I had gotten into a routine and while I noted that she had the antibiotic, I didn't check it against her allergies.

    A while later I was called back to the room by the nursing assistant who said that the resident had been complaining that she was nauseous. I gave some Gravol for it, checked on her a little while later and everything was good.

    Throughout my shift, I had also double-checked the order as per protocol.

    What I didn't realize until much later into my shift, was that she was allergic to that antibiotic. So the thing that caught me, was that although it was in her chart, the doctor had ordered the medication, one nurse had checked the order, pharmacy had filled the prescription that we are the last people to correct a medication error. I remember learning specifically about this in nursing school (I believe in pharmacology), how we are the last step to prevent an error, but it wasn't until that night that it I really understood what they had been talking about.

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  2. 16
    I gave bed A's meds to bed B. Bed A was on meds for hypertension and diabetes, bed B had none of those issues, she was post op. Both patients were named Mary, and I did check identities before giving the meds, I was going to bed A initially, and then found out she was Mary A and switched. At that time our hospital specifically said not to bring the MARs into the room with you, but that policy changed after my error.

    Mary B almost coded that day and had several days worth of hypoglycemia and hypotension. I was surprised how long the effects lasted, and I was assigned to her every day. I got her into that mess, and I managed to get her out. The patient and family were informed immediately, and could not have been more supportive. The patient's daughter was a nurse, and quite high up in the hospital hierarchy. I felt guilty because I didn't fall apart that day, or quit, but I don't think there's been a day working that I don't remember that mistake.

    Anyone that says they haven't screwed up royally hasn't been working long enough. If you hear about someone else's error and think "I'd NEVER make that mistake!" Don't sell yourself short, you too can have a moment of pressure, or inattention, so if you get that funny feeling, go back and recheck what you're doing.

    I've been saved from med errors when a patient expressed concern about what I brought them. Tell patients what you have, and what it's for before they take it, and stop if they notice something wrong. Running through the pills with Mary B that day would have caught the error.
  3. 0
    I took care of a family member, actually my husband's family member. Not taking care of family isn't always an option in a small rural hospital, but I try to avoid it as much as possible, since having to call my FIL and tell him his brother died!
  4. 10
    I've posted this before-- there's a whole thread on errors new grad make. Still scares me to think about.

    the worst thing that happened to me as a new grad was the day i got a lady with fresh postop carotid endarterectomy whose bp was too high. the chief of surgery was right there and told the intern (what we now call an r1) to give a medication called apresoline iv push stat to drop her pressure to safer levels, to avoid rupturing her carotid, and to repeat it q5minutes until her pressure was under control. it wasn't a familiar medication to me, but i figured the chief of surgery oughta know so i went and got it out of the drawer and gave the first dose, the intern at my side. five minutes later, pressure is still too high. intern says, give it again, so i did. same thing five minutes after that. and at twenty minutes.
    and then her bp went down. and down. and down, and down, and down, and the woman who was awake and talking to us after her elective endarterectomy drowsed off and went to sleep. and she never woke up again, because we dropped her bp so far she stroked out.
    chief of surgery denied ever having said any such thing and hung the intern out to dry, which was devastating to him. i was finally able to go look it up and learned that the peak effect of iv apresoline can be 30 minutes after the dose, so of course we gave her waaaaayy too much. i was devastated.
    moral of the story was that i learned never to give anything, even in an emergency, that i didn't know about. if i had no time to look it up, i would hand it to the md or someone else to give. of course, in time i knew all the emergency drugs, and that became a moot point, but still.
    sometimes i still see that woman in my dreams, and it's been almost, good grief, forty years.
  5. 2
    I am a new nurse, so I know this mistake will not be my only one. But now I'm more attentive about patient safety because of it. I had a lady who came for an intractable migraine status post concussion from a fall. I gave her a migraine cocktail of Benadryl, toradol and Thorazine. I actually made two mistakes really. First, I hooked up the Thorazine as a piggyback, and set the rate higher than it should have been. It should have been a secondary on a pump. Second thing I didn't do was put her back on the monitor. She'd just come back from the bathroom, and was not on the monitor. This all happened at change of shift. When the night shift nurse went in, the patient was completely snowed and her o2 sats were very low. She well could have gone into respiratory arrest if the night shift nurse didn't go in any sooner. Her sats improved with oxygen and she eventually woke up some more. Thank God it wasn't worse. Moral of the story: Maintain situational awareness at all times, especially with regard to patient safety. Especially after giving a medication that reduces respiratory drive.
    CLoGreenEyes and GrnTea like this.
  6. 2
    My first big nursing mistake was taking a job at the Nursing Home from Hell, despite warnings from colleagues who had worked there, because they were offering a substantial pay raise. We needed the money, and I'd worked in toxic environments before (though not in nursing), so I thought I could handle it. After 2-1/2 days of training I was on my own with 15 high-maintenance patients, LNAs who only did ADLs and feeding, and no help. I lasted 6 weeks.

    My next mistake was taking a job at the facility I'd just left. I was in a different building, with some of the same problems, plus a bunch of others. Among other things, I was the only person on my shift who didn't smoke. If anything happened, I had to respond because I was the only one in the building. My boss yelled at me for questioning a morphine dose that turned out to be very wrong.

    One night, they needed overnight coverage. I was still finding my way around the building. I didn't even know how to lock and unlock the doors. However, I'd been out of work, my husband needed surgery (which kept him out of work for 10 weeks), and we needed heating oil. I was desperate, so I volunteered for the shift. I had 60 patients and 1 LNA. I screwed things up very badly. I was already on thin ice at that facility, and that was the last straw. I was suspended, then fired.

    I've had 2 jobs since then. Both were pay cuts, but working conditions were much better.

    I've learned that money isn't everything. And I will never work LTC again.
    Last edit by Not_A_Hat_Person on Jan 31, '13
    Anna S, RN and GrnTea like this.
  7. 0
    Quote from Not_A_Hat_Person
    I had 60 patients and 1 LNA.
    what? how is this legal, and how are you the one who got in trouble?
  8. 0
    I am in my last semester of nursing school...while I have had a few opportunities to do IV's, not all of my classmates have. They taught us in simulation but many have not had the chance to do it in an actual clinical setting, on a patient. It is nothing against the nursing program, its just dependent upon the learning opportunities that arise during your clinical times and the type of floor you are placed on. Good luck in your program!
    : )
  9. 0
    Quote from rita359
    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.
    I did that in all the clinical settings I went to. I told the nurses if they had something they thought I should see and learn, to please let me know! My teachers were also aware that I wanted to see as much as I could.
    I later used that when I was an RN and knew students would be coming around that day. I worked until 8am, they came in at 7am. So I made sure to keep blood work until they came around and asked them if any of them wanted to do it. The teachers loved it, and the students loved even more that I volunteered to go with them instead of their teacher, since I knew how much it would stress me out to have them breathing down my neck doing new skills...
  10. 0
    2nd day on orientation, I was orienting with one of the LPNs. We were hanging a lasix drip, which was not programmed in our alaris pump library. The label wasn't very clear on the rate,--we ended up giving the entire bag in one hour. Luckily, no harm came to patient. It was an awful feeling though, when I figured out what happened.
    Lesson: if confused, check EMAR again or call pharmacy! Also, I am now VERY compliant with med scanning. Many people on our floor tend to scan pt labels outside the room, and sign out meds that way--usually because our WOWs (laptop) have very poor battery life or they don't want to wait for the new wired in computers to load up. Now I just suck it up and wait for the computer.

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