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

Nurses General Nursing

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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 forgetting something, or even something as simple and innocuous as saying something to a patient or colleague before you could stop yourself!

The reason I think this thread is a good idea is that it shows that we're all human, we all make mistakes, and it will help us learn fro each other's mistakes, especially me and my fellow students, and ease our nerves a bit, so we know that we're not the first to ever take 15 tries to lay a central line or need 5 minutes to adjust an IV drop, but instead we're just part of a larger community who's support we can count on!

To be fair, I'll start.

I was working in a pharmacy, and a patient was prescribed 2.5mg Warfarin. I prepped the script properly, and accidentally pulled a bottle of Warfarin 5mg. I counted out the proper amount of pills, and bottled em up, passed it to my pharmacist for verification. She verified as accurate, and we sold the medicine to the patient. The patient's wife called a few days later and talked to the pharmacist who verified (who was also the pharmacy manager), and we discovered the mix-up. Luckily he hadn't taken for very long, but it terrified me. I could've been responsible for someone dying because I didn't double and triple check the meds. I got reprimanded, and she pharmacist got nothing. (this was also the same pharmacist who misplaced a full bottle of CII meds for 48 hours - she found it behind some loose papers on her desk)

I learned that there is no detail too little to double/triple check in medicine. I learned that it's never acceptable to "get in the zone" and work on reflex, and that every action you take has consequences; some more deadly than others.

I have got another one for you. I was teaching a patient how to use an inhaler. I said quote "you have to take a deep breath in order to get the medicine down into your lungs to open up your areolas" . It wasn't until I walked out of the room that I realized I mean alveoli. hmm yeah very embarrasing. by the way it was a male patient :)

Didn't question the doctor when she ordered a medication with a similar name instead of the intended one. I was new and shy at the time, and figured that it was an usage I wasn't aware of. Nowadays I'd just ask what the heck she was ordering that for. Luckily, no harm done, and I learned that docs really do make mistakes that we have to catch.

Gave the wrong patient the meds. No good reason - it was the end of my 4th 12 hour shift in a row, and I got distracted in between the med cart and the table and gave it to the previous person on my list instead of the correct person. Again, no harm - the medication was the same med, same dosage that she was supposed to receive at HS, so we just held the HS medication. I stopped doing 4 shifts in a row and double-check myself if I get distracted between med cart and patient (this is LTC and we have no wristbands to check).

Discussions like this are so helpful for us nurses - it just takes one moment of carelessness (or naivete) to make a mistake ... and once we do, hopefully we'll learn from that and move on. I've been a nurse for a little over 2 years, working on a tele unit for 15 months and now working on a medicine unit at a new hospital. In just the last couple of weeks during orientation I've made so many mistakes! I think when we all own up to our mistakes with honesty, knowing we were doing our best, we can move forward and not be hindered by shame. It's easy to feel so down on yourself and worried but those feelings only make things worse, in my opinion. Ok, here are mine from just the last couple of weeks...(yikes, there are a lot! learn from me!)

1. Believing a 350+ lb paraplegic patient that he could transfer himself from the bed to the wheelchair using the overhead trapeze and standby assist...3 of us nurses at the bedside and the patient almost fell to the floor during this transfer! I urged him that we should use the lift equipment but he INSISTED that that was unnecessary, as he was going home and very anxious to get out of the hospital. We are taught to listen to our patients but in this case I should have listened to my GUT, and NOT the patient. Not only could he have injured himself further - all 3 of us nurses assisting him in the transfer could have severely injured ourselves in the process with that much dead weight involved. ALWAYS use lift equipment or be 100% confident in the people you are trusting to move your patient (such as a lift team or several muscular men)! And don't always abide by what your patients think is best for them - use your judgement and act for their safety first and foremost.

2. When drawing a lab from a central line, double check and ***make sure**** nothing is in the line upstream that could alter the test result (whether an electrolyte or drug level, etc.). I drew from a central line a potassium level. I looked upstream and saw that the potassium piggyback bag was empty and had been done for quite some time with the maintenance fluids (NS) below it running into the line. I thought to myself, "The potassium's done, so I don't need to disconnect." I drew from another port on the central line while the supposed maintenance fluids were still running, and lo and behold, the K result was critically high at over 10.0. There must have been some K+ still in the primary tubing which threw off the result. Better to be safe than sorry - ALWAYS just disconnect or put EVERYTHING on pause while drawing blood from a central line.

3. I was under the assumption that pharmacy pretty thoroughly reviews allergies before putting any MD drug orders through to the pyxis. I should never make this assumption. I had a patient with an allergy to iron and was given a multivitamin (new order). Thankfully she questioned what the pill was and had the insight to think it probably had iron in it, so she didn't take it. This particular lady had about 25 drug allergies so it's not surprising that she's very aware but I should have caught that too...

4. Don't EVER put a controlled substance into a general med stocking area. I pulled out ~10 meds for a patient, including a fent patch. Another nurse had already given (a different) fent patch that morning to treat her pain and my pt was unable to swallow so I ended up not giving her any of the meds I'd pulled from the pyxis. I'd completely forgotten that one of those was a controlled substance (the patch) and put ALL of the meds I'd pulled for her into a plastic bag and into her little cubby inside the pyxis tower for return to pharmacy. Pharmacy came back to our unit and asked the manager who put the fent patch back into the pyxis and of course I owned up to the mistake. Always return all of a patient's meds individually into their pyxis cubbies (not only are they charged every time you pull the med from the pyxis) but you could make the same mistake I did and put a narcotic patch in an open area inside the pyxis machine. Though unlikely, another RN could have opened the pyxis tower, then opened the plastic bag, and taken the fent patch...and my license would've been on the line if that fent patch was never recovered.

5. Never forget to tell the next shift about timed lab draws. I had a pt on a lidocaine drip with lidocaine levels to be drawn Q8 hours. She of course had a central line so these draws were to be done by the nurse and not the lab. I failed to mention this while giving report to the next shift. Even though she would have seen the order for this on the pt's profile, it could have easily been overlooked and our pt may have been getting either sub-therapeutic or toxic levels of the drug without the Q8H draws to monitor.

6. Never hang a piggy back med onto a pole and plan on "coming back" to it after you administer oral meds. I did this yesterday and the pt noticed that it wasn't connected to her and just hanging on the pole. Not only was I mortified, the pt didn't get their medicine on time. If you have a piggy back med, hook it up and program it ***right away*** before trying to do something else and you forget about it!

7. Always wear gloves when doing ANYTHING with a central line. Even if you wash your hands thoroughly upon entering the room and scrub the hub with alcohol for over 15 seconds - it's best practice to wear gloves when hooking anything up or touching a central line. If anything else it eases a pt's fears about any bacteria entering their line.

8. Remember that a LOW temperature can be a sign of sepsis, just as much as a fever. Don't discount this in your sepsis assessment just because a pt doesn't have a fever. I did this erroneously this past week and my preceptor caught it and, with this one added piece of information, notified the MD that the pt screened positive for sepsis (which, incidentally, she was already being treated for).

9. Make note of all timed blood sugar checks on your brain with little check boxes, particularly the ones where there is no insulin ordered as a reminder to you (such as post-pradial sugar checks). I forgot to check post-prandial sugars in one of my pts after breakfast and lunch because they didn't have any insulin ordered and it just slipped my mind.

OK, there you go. Some mistakes from just a few weeks on the new job! We need each other if we're going to practice nursing safely! Thanks to the author of this original thread and all the nurses out there that have responded so that we can ALL learn from each other's mistakes.

I gave colostrum to a baby that was not from that baby's mother. Lesson learned - ALWAYS ALWAYS check meds and labels. Don't rely on another nurse's judgment and accuracy.

I always seem to rely on nurses report and now I'm finding out that I shouldn't and should check stuff on my own. My night nurse told me she didn't find the order and it's not in the chart so I asked the doctor when he turned up that day and he showed me where it is in the chart and it was not even hard to find. Embarrassing!

(Parenthetical remark: Nobody is allergic to iron-- everyone has an iron molecule smack dab in the middle of every hemoglobin molecule in his body. That's what makes it red. :) )

Haha that's right

GrnTea, yes, obviously we all have iron in our blood...but one can have an allergic rx to iron - though it is extremely rare - in the form of oral supplements. According to this patient, she goes into anaphylaxis if taking iron tablets ... as I mentioned she had ~25 listed allergies in her chart so God only knows if all of those were TRUE allergies or perhaps adverse reactions of some kind. Perhaps she had that reaction initially to a compound inside an iron tablet and not the actual iron mineral itself...I don't understand the physiology behind an iron allergy but apparently it exists! :)

I unzipped a body bag after a dead patient made respiratory efforts...after the massive amount of Epi kicked in.

He"lived" 2 more days ...dead on a vent.

So sorry , Al.

I unzipped a body bag after a dead patient made respiratory efforts...after the massive amount of Epi kicked in.

He"lived" 2 more days ...dead on a vent.

So sorry , Al.

So you should have left him in the body bag gasping for air?

I unzipped a body bag after a dead patient made respiratory efforts...after the massive amount of Epi kicked in. He"lived" 2 more days ...dead on a vent. So sorry , Al.

Omg! I would never zip a body bag again!

He was most certainly NOT gasping for air. His autonomic nervous system kicked in ( from the epi) and made weak inspiratory efforts.

He was end stage COPD, already suffered enough and never should have been coded in the first place. To re- code him , let him linger 2 days on a vent was cruel.

So you should have left him in the body bag gasping for air?

Yep. Once somebody is dead enough for a body bag, it's a good idea to leave him in it. I have never seen that work out well. (I had a lady who was pretty darn close to dead when we sent her to the OR from the ICU and declared dead after flunking surgery. While they were waiting for the orderly to take her to the morgue some med student wandered in and reached into her open chest to practice open heart massage. Damned if it wasn't sorta moving anyway, he screamed, and she got sewn up and brought back to us. But not for long. Again, sorry, Marie.)

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