What's the biggest mistake you've ever made as a nurse? What did you learn from it? - page 7

by Mini-Murse 96,158 Views | 159 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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    Quote from sharpeimom
    never try to have a conversation with a 400#+ h*ll's angel pt. alone. i am 5'4" and weighed about 110#, and was absolutely no match at all. he grabbed me and suddenly i was airborne. he yelled "make a wish, b*tch! he had grabbed me by my right shoulder and left hip.
    LAWD HAVE MERCY!!!!
  2. 6
    I administered Rocephin to a patient with gonorrhea, and I had not twisted the needle tightly enough on the syringe. Thus , medicine leaked out when I administered it. The doctor said the patient would have to abstain from sex & return for re-testing in 4 weeks as a consequence. I flagged her chart so I could make sure she returned. I called & called, but she never returned. If there was a slight bump in gonorrhea rates in my community during that time frame, you're welcome!
    ARTPOPIST, krisiepoo, sweetf, and 3 others like this.
  3. 0
    The mistakes that stand out for me:

    1. Giving a different concentration of a low-molecular weight heparin to a pt; right med, wrong dose...was on orientation for a week, new preceptor...first incident report as a nurse. Told the pt immediately, was super cool about it, doc was too, pt survived.

    2. Gave pt med AFTER another nurse gave the dose of medicine. Assignment was changed. That nurse was very ineffective at communication, teamwork, and was known to be unsafe...medical debris easily accessible to the children...literally rushing around to make sure kids did not have access to being injured, infusing incorrect feeds to the wrong pts. Job has ONLY paper charting, no high tech fail safes. Instituted a LOT of policies because of a lot of issues with this nurse. FINALLY got fired after her almost 4 years of "service" to our pediatric facility. Still makes me hyper vigilant to check and trust my gut judgement, and literally harass people and continue to check the assignment throughout the day for any "surprises"... :-/

    A LOT of near misses in between and after the last incident, even in declining or emergency situations. I just try to remain as safe as possible...
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    Mine happened just last night! Hence the reason I searched "mistakes" on here as soon as I came home, crying.
    These happened with the same patient:
    1. Patient had order for lorazepam 1-2 mg IV for seizures. I read the order as IM and gave as such. Realized that this morning, and also realized that I wouldn't have been able to give it IV anyway, because I am not a critical care RN. Called the MD on-call who was unphased and said "Oh, okay! Whatever" haha.

    2. Also this morning, realized my patient's foley cath output was ohhhh about 100mL overnight, and I was so preoccupied with the 1 million other tubes coming out of her, I didn't even realize.

    I actually want to quit and hide in a hole. 1st year of nursing is sucking.
    sweetf likes this.
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    I infused an entire unit of platelets on a little girl in under an hour. One of the clamps that should have been closed (the clamp running from the bag to the syringe) wasn't fully closed. So while the platelets were running from the syringe pump they were also running by gravity. Luckily nothing happened.
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    I had a resident on 3 anti seizure meds. One med, I didn't know it wasnt for pain but for seizures(it was in narc box). Brand new nurse, overloaded with residents, decided to give his meds last. Shamefully I hadn't looked up the reason for the med. He got it, but like an hour late! I can't believe I didn't look it up in the drug book. I felt so bad when I finally did look it up.
  7. 1
    Quote from Nugget
    Mine happened just last night! Hence the reason I searched "mistakes" on here as soon as I came home, crying.
    These happened with the same patient:
    1. Patient had order for lorazepam 1-2 mg IV for seizures. I read the order as IM and gave as such. Realized that this morning, and also realized that I wouldn't have been able to give it IV anyway, because I am not a critical care RN. Called the MD on-call who was unphased and said "Oh, okay! Whatever" haha.

    2. Also this morning, realized my patient's foley cath output was ohhhh about 100mL overnight, and I was so preoccupied with the 1 million other tubes coming out of her, I didn't even realize.

    I actually want to quit and hide in a hole. 1st year of nursing is sucking.
    You can't give lorazepam IVP? We give it all the time on MedSurg.
    ama3t likes this.
  8. 1
    Quote from SoCalGalRN

    You can't give lorazepam IVP? We give it all the time on MedSurg.
    That's what I was thinking. I am surprised by these things I read on here and wonder what caused these policies to be placed. Probably things that belong in this thread.

    ~ No One Can Make You Feel Inferior Without Your Consent -Eleanor Roosevelt ~
    sapphire18 likes this.
  9. 0
    Quote from SoCalGalRN
    You can't give lorazepam IVP? We give it all the time on MedSurg.
    I've worked at a couple of facilities and was always able to give lorazepam ivp. Never given it IM. Haldol is another story. I worked at a facility where only ICU nurses could give haldol ivp d/t prolongation of QT if administered too quickly. We could give IVPB.

    Yeah it sucks when you make a medication error. I've made a couple in my years. I was still a new nurse on orientation and heplocked a dialysis catheter on a pt who was HIT +. I let the nephrologist know. They wondered why I called about that. Likely none of it got to them systemically.

    Just a few months ago I had 5 patients and they were all on some sort of drip (I was the only nurse with patients on drips that day and I got them all). I started a bumex drip and I am not as familiar with that as other medications. I programmed the pump incorrectly. I believe I was supposed to have it going at 3 ml/hr and had it going for 3 mg/hr (don't quote me on those numbers). I was used to lasix gtt's which are 1 mg = 1 mL. The nurse on the next shift didn't catch it either and the nurse on the following shift caught it 6 hours into her shift. I apologized to the nephrologist the next day and he told me not to worry about it. The particular nurse who assigned this load to me does a horrible job of making assignments. I've complained and my manager blows me off about it. My educator talked to me about the mistake. I told her it was not a good day for me on the unit and they shouldn't assign all the drips to 1 nurse when there are 7 nurses on the unit. That wasn't an acceptable excuse.

    Unfortunately mistakes happen. We're only human! We try our best and would never intentionally harm someone.
    Last edit by rn undisclosed name on Apr 4, '13 : Reason: wording error
  10. 1
    Patient was supposed to get 3 units of Novolog but ended up getting 7 units because my CNA mixed up the blood sugars and told me the wrong one. Patient was okay and actually their sugar ended up being even higher the second time around. Moral of the story: now I make sure that glucometer gets docked so I can actually see the blood sugar results upload into the computer and into each patient's individual chart.

    This was a mistake I made somewhat recently. MD ordered a unit of blood to be given. Apparently this order was put in at 12:30 and was missed by the dayshift nurse AND me. Patient was to go for an amputation the next morning and the surgeon calls me in the AM and asks,
    "Did Doctor X order any blood?"
    *frantically searching through the patient's chart and looking at all of the patient's active orders* "No, sir, I do not see an order here."
    "Oh, okay then. I will call Doctor X. Thank you."

    A few minutes later one of the CNAs (and I don't know why she was the one to tell me or why she spoke to the doctor) came up to me and said, "umm just so you know, the patient's surgery got cancelled and the doctor called and was ****** and he wants you to call him back NOW." I just wanted to cry, crawl under a rock and be left alone. I called the surgeon, and surprisingly I didn't get chewed out, they just told me the surgery will be post-poned until tomorrow and the patient will just get the unit of blood during their scheduled HD today.

    I spoke to the dayshift charge and told them what happened, they said "well whoever it was before you should have been the one to administer the blood" but I told them that since it wasn't completed on their shift, it falls on my shift and it became my responsibility.

    So what happened? The MD ordered 1 unit to be transfused but wrote that in the patient's hemodialysis orders. We have computer charting at work and we have been told by management not to start the HD orders; only the dialysis RN is supposed to do that. So, naturally, I ignore them. I just see "Hemodialysis" in the planned state. When I looked at the plan, there was the order: "transfuse 1 unit of PRBCs." I could not have initiated that order without initiating the entire HD plan. Of course, I didn't see this until after I had learned the surgery was cancelled and that the MD indeed ordered a transfusion.

    Regardless, I told the dayshift charge I would take full responsibility for whatever happened...I told the patient and they were very upset with me, as they should have been. Anyway, the patient went for surgery the following day and everything turned out to be A-OK. Thank goodness.
    smartypantsnurse likes this.


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