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

Nurses General Nursing

Published

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.

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.)

Oh my. Wow. Still have lots to learn.

My first and biggest mistake was as a nursing student.

The RN I was working with had no interest in communicating with me from the start of the day. When it was time to give meds I checked the chart and saw the meds weren't given yet. I checked with the RN who verified she hadn't given them so I figured I was good to go. I gave the patient his meds then when I went to chart I saw the meds were suddenly charted as given. My heart was in my throat. I brought this to the RN's attention who said she had already given this patient his meds and that I "misheard" her - which I definitely did not - she was just not listening to me and brushing me off the same way she had been all day long. Turns out she HAD given the meds and charted late.

The kicker was that this patient was not entirely lucid - but he did say to me, "Oh, didn't the RN already give this to me? Oh well, go ahead!" I didn't think anything of it because of his mental status - but sure enough, he knew what he was talking about.

Fortunately it was some mild pain meds so THANKFULLY, other than feeling a little extra happy, there were no side effects.

While I was devastated to have made a med error ALREADY in my career, now I'm glad I "got it out of the way" early. I certainly won't be making the same mistake again and will LISTEN to my patients and triple check!

I learned to be a better nurse.

Specializes in ICU/CCU, PICU.

Many mistakes but I've learned from every one. Those that keep with me.

1) Gave 25mg PO metoprolol instead of 12.5. I check the MAR but overlooked the part that said 1/2 tab.

2) 1 of my patients had to go to MRI at change of shift. The Resource nurse who travels with patients was pregnant so she couldn't go. The Charge RN arranged for the Resource RN to cover the other patient and the oncoming RN would go to MRI instead. I gave report at change of shift to the Resource RN. Well after that I left, the Resource RN did too and left the patient with no RN covering. No one realized it until 0100 in the morning (I left at 1900). The Resource RN denied she ever took report and I was then accused of patient abandonment even though the Charge RN vouched for me that was the plan and the Nurse Manager saw me "talking to her (Resource) but didn't know what it was talking to her about". I learned to always write "Care endorsed to xxx using SBAR format" in the EMR after giving report.

Specializes in Neonatal nursing.

You are not the first and wont be the last but your mistake will help improve your own and others practices and policies. We had a similar incident recently too in the SCN and the person involved felt terrible but totally owned up and it has made us all more vigilant. It doesn't matter how experienced or inexperienced you are, we are all human and all make mistakes but that is how we learn and get better. Thanks so much for sharing.

I've learned to never ask questions on Allnurses! Biggest mistake of my career so far hehe.I think my biggest mistake was not working in med surg first. I became an RN after being an lpn for 4 yrs,but lo and behold the recession came in 2008,the same yr I got my Rn license,so I guess you can figure out the rest.I moved,was willing to travel,etc but got nowhere.Now as a result,I'm locked out of a wider variety of jobs. The prison doesn't want to hire nurses with no med surg backround.

1) Gave 25mg PO metoprolol instead of 12.5. I check the MAR but overlooked the part that said 1/2 tab.

I know it's common practice in SNFs but the standard of care is to chart the DOSE, not some fraction of a pill unit. What happens if the pharmacy gets a source of 12.5mg pills and nobody notices, but they are so used to cutting his pills in half they are now giving him half doses? Why do we teach med math, anyway? See if you can get this changed in your pharmacy p&p/medical therapeutics committee meeting.

I've done that before and got busted! I got wrote up for false documentation because I didn't look at the site. My DON was really cool about it and It was seriously my second day working as a nurse so I was very much on the clueless side of things but she taught me two very important lessons that I have carried and kept in high regard ever since. 1) False documentation is a big no no and they can yank your license from you in a heartbeat for it. 2) Luckily, it was normal saline. If it would have been say a K rider or Vanc or if I would have pushed the Phenergan she had ordered, those meds can and will cause tissue necrosis which could have led to major infection and damage. When your new you think something as silly as glancing at someone's iv site is no big deal but one thing about nursing, it is always the little, fundamental things that were drilled into our heads since the first day of nursing school that can cause lots of damage including losing your job and/or being reported to the board. I'll tell ya though, I haven't made that error since and ill never forget it. :)

I know that the laws vary by state but here in WV, you do not touch an IV in nursing school at all. You learn how to spike and hang bags and work the pumps etc but yeah, we are trained on the job or our employers send us to a 3 day class and we get certified in IV's PICC's Midlines for two yrs. I actually learned IV's as an LPN working on a Med Surg floor.

You poor thing! LOL! I've been in your shoes and I know exactly how you feel...but honestly, those are the kind of dumb mistakes that a new nurse makes and your higher ups know this. I did some of those very things. But, when I forgot to turn on the pump after I hung the piggy back, I got a med error on me because my DON happened to see it and it was like two hrs overdue...A girl stuck a fent patch in the one of those little cubbies and got fired for it. It is really scary because nursing is a heck of a learning process and you don't learn hardly anything you need in nursing school. Wait until this time next year after you've worked for a full year and you will be a completely different nurse. You will know how to think better and you'll have a routine established. But like I said, some of those things you mentioned above are considered med errors and the blood sugars not getting checked are some kind of infraction as well and honestly, the healthcare field has such a big turn over because facilities will fire nurses for mistakes like that, even though theyre so stupid and were all human....im speaking from experience. I got screwed really bad and fired for accidentally signing off a neb tx and then forgot to turn the machine on. And just the week before I was in for my evaluation with my DON and administrator, and HR rep and they bragged and bragged on what a wonderful nurse I was and how they wished the other employees would take notes and they went on and on and made me feel so good then i got canned over albuterol the next week...that was devastating...now granted, they fired 15 other people on the same day they fired me because we had a really bad state survey and corporate decided to just wipe out the whole staff. They escorted the DON to the time clock and woouldnt let her get her stuff and she had worked there for 37 years!! Anyways thats way off the subject but the best advice I can give u is even though it takes that one extra second to double check or to ask someone, it is worth it. I had to start double checking myself for a while when I was a new nurse because like you said, my hands would be full of meds so i'd ha-15mg the iv fluids and meds on the pole first then give the PO's etc and then id totally forget to turn them on so I had to start making two trips or if I was absolutely swamped, id set the alarm on my phone with a reminder that said "go check IV poles" it would go off about 10-15 mins after my meds were passed and there were several times I went in and found them. If I would have got caught without one running and got another med error write up, in that facility, it was grounds for dismissal so I had to do whatever it took to make sure I had everything done and administered correctly and on time. You'll be fine!! Just know, the mistakes you spoke of in your post, you'll never make them again!!! haha

Specializes in NICU.

Pts blood sugars were really high all day... Couldn't figure out why...called the doc, trying to figure it out. Re check the MAR....I have her sliding scale humalog in the morning but missed her 44u of lantus...*facepalm* it was written under the sliding scale and beside the sliding scale it says *see diabetic profile* so I always turn to that page and miss anything underneath. Turns out I had missed it the day before too. I was in my final placement as a student and my preceptor gave me crap for it!

Specializes in NICU.
missed her 44u of lantus...*facepalm*

Sorry not Lantus, I believe it was Levemir....

+ Add a Comment