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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wanderlust99

793 Posts

Specializes in ICU/PACU.

I don't want to say, but I now triple check when programming IV pumps.

KRVRN, BSN, RN

1,334 Posts

Specializes in NICU.

I gave PRBCs to a micropreemie (all 10mL of it) over 30 min instead of 3 hrs. Just missed one zero on the pump. The MD wasn't mad, it actually benefitted the baby because she was hypotensive.

chrisrn24

905 Posts

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.

Agree!

sunnyskies9

87 Posts

reminds me of the time I had this one pt who was post op PEG placement. It was like her 4th or 5th PEG placement because each one prior had some sort of complication. Additionally, all of these PEGs were placed by the same surgeon, who also happens to be the most rude MD you could possibly imagine. So I go to administer her meds and flush the tube and notice all the water is leaking out, and there is a huge gaping hole in the tube!! Not sure if it was caused by me flushing the tube or how on earth that happened. Of course, I am terrified to call the surgeon. But this is how it went down: "What do you mean there is a hole in the PEG tube?" "Dr, I'm not sure how it happened." "Well I will be up to take a look at it." So he shows up a few minutes later, and asks me to show him the PEG tube. He takes a look at it and was like "well, guess we can't use that anymore." My reaction was one of mostly relief that he didn't chew me out in front of the pt. but felt so bad for the patient and the embarrassment of telling them what happened.

my worst and first mistake that comes to mind was running a piggyback antibiotic into the PPN line, like a dummy. luckily, the patient didn't have a reaction.

mluvsgnc

178 Posts

Specializes in pediatric.

As a student in clinical, I gave a SQ injection of Octreotide into a pt.'s deltoid. As I was administering it, he was saying, "Ow! That burns! Ow! Hurry!" Well... lo and behold, even though I had looked up the med for precautions, contraindications, etc., I failed to look at the IM implementation, which says specifically "avoid using deltoid site due to pain of injection." That will never happen again. :(

SL2014

198 Posts

Specializes in Case Management, ICU, Telemetry.

I had a patient in ICU who suddenly developed a unilateral fixed dilated pupil, I called the critical care attending, he came flying up... I had TOTALLY FORGOTTEN THAT THE OPHTHALMOLOGIST CAME AND SAW THE PATIENT 15 minutes before to dilate his pupil and check his macula and vasculature... I even had a conversation with him about dilating the patient's pupil. I felt like SUCH a moron.

SL2014

198 Posts

Specializes in Case Management, ICU, Telemetry.

Oh and while in training I had an out of control patient... My preceptor said, "be really careful, you don't know what these people will do" I'm like "ya ok it's oral care, I got this"... Well... she didn't like oral care, she became incredibly ****** off and extubated herself (while in soft restraints) faster than I could say Ativan... I screamed for help. I got crap for it until I transferred out of the unit.

katierobin23

147 Posts

Day two on orientation in the NICU (my first job as a nurse), I assessed an IV all morning and didn't see anything wrong with it. The site wasn't red or leaking....but the leg was swollen, badly. The baby was getting Hyperal and Lipids (TPN) which tears apart veins and tissue really bad...learned that quickly. I wasn't assessing the leg compared to the other one, so I saw a chunky baby leg and didn't think anything of it...but this was a premie with chicken legs. By the time it was caught, the baby lost most of the skin on the top of his foot and everyone who saw it said it was the worse they'd ever seen. My preceptor felt awful because she didn't check behind me and I was brand new...but I felt worse. It was horrible. It was probably only three hours worth of TPN that had infiltrated but it was so rough.

Now I watch my IVs like a HAWK! I'll pull it and restart it in a heartbeat if I don't like it!

Also, I've become a big advocate for putting in a PICC for long term TPN, which is standard protocol, but not always done in a timely manner.

Also, about starting IVs, I never learned about it in school..never did the fake arm thing. We were told our hospitals would want to train us themselves and/or would have an IV team to do them.

kaenee

2 Posts

I committed and error during my graveyard shift and that was the reason why I ended up here to know if someone committed the same mistake like I did but alas, I found none.

Anyways, my mistake was totally idiotic in nature.

My patient was on NPO but I gave her 30cc of water and her medicine but it wasn't just an ordinary medicine, it was an oral hypoglycemic agent Glimepiride and she was scheduled for a Fasting Blood Glucose at 6:00 AM. I gave her the medicine at 5:00 AM.

I was so stupid that I even reminded her not to take anything before her blood is withdrawn but I ended up eating those words. When she was done taking her medicine, she then asked me about her NPO status and then it dawned on me. I was like splashed with cold water all over my body. I don't know how to react in front of her. I even forgot how I responded to her question. All I remember was I went directly to my preceptor and she was horrified but she wasn't mad when I told her about it. We then went to our team leader. She was calm and she wasn't saying anything. She then told my preceptor to call the lab right away to get her blood. My guilt doubled when they told the lab that the reason why they would draw the blood early is because the patient couldn't wait anymore and that she was hungry. They were forced to tell a lie on my behalf and I couldn't help myself to feel worse about it. I think it was around 30 to 45 minutes after the medicine administration that her blood was drawn out.

I just hoped that there would be no significant difference but I doubt that would happen. T_T

0.adamantite

233 Posts

Specializes in Acute Care - Adult, Med Surg, Neuro.
I committed and error during my graveyard shift and that was the reason why I ended up here to know if someone committed the same mistake like I did but alas, I found none.

Anyways, my mistake was totally idiotic in nature.

My patient was on NPO but I gave her 30cc of water and her medicine but it wasn't just an ordinary medicine, it was an oral hypoglycemic agent Glimepiride and she was scheduled for a Fasting Blood Glucose at 6:00 AM. I gave her the medicine at 5:00 AM.

I was so stupid that I even reminded her not to take anything before her blood is withdrawn but I ended up eating those words. When she was done taking her medicine, she then asked me about her NPO status and then it dawned on me. I was like splashed with cold water all over my body. I don't know how to react in front of her. I even forgot how I responded to her question. All I remember was I went directly to my preceptor and she was horrified but she wasn't mad when I told her about it. We then went to our team leader. She was calm and she wasn't saying anything. She then told my preceptor to call the lab right away to get her blood. My guilt doubled when they told the lab that the reason why they would draw the blood early is because the patient couldn't wait anymore and that she was hungry. They were forced to tell a lie on my behalf and I couldn't help myself to feel worse about it. I think it was around 30 to 45 minutes after the medicine administration that her blood was drawn out.

I just hoped that there would be no significant difference but I doubt that would happen. T_T

We have a protocol for fasting patients. I've never had one except for patient's NPO for surgery. Either way the physicians usually say what to do about certain medications. Many times we give patients their blood pressure medications with a small sip of water prior to surgery.

With insulin and oral diabetic medications, we are instructed to contact the MD for clarification of dosing when a patient is NPO. Many of our patients aren't on oral diabetic medications because of recent contrast dye or because physicians prefer insulin when a patient is in the hospital.

I guess your mistake is more that a nuisance to the patient if she has to repeat her fasting, also be sure to clarify if how a patient should take their diabetic medication if they are NPO. In her case, I would have probably waited until the lab had been drawn, had her order her food, and then give it to her if appropriate.

Also remember that if a patient is diabetic and NPO MD's often want blood glucose checks Q4-6H hours, particularly if they are on diabetic medication or insulin.

ICURN3020

392 Posts

I had a patient with prostate issues. I was told by the prior nurse that the patient has the prostate cancer as well. Not as a bedside report!

Anyway, when I was giving report to a different nurse at the end of my shift, we did bedside report. And I told the nurse that the patient had prostate cancer, in front of the patient. Guess what? Patient got freaked out saying "what! I don't have cancer!, etc". Doctor happened to come in and witness some of that too by the way. The reality is, patient didn't have the cancer. When we left the room, doctor approached me and said that the patient didn't have a cancer and I shouldn't have said that. Fortunately, he was one of the very nice doctors, and I told him that that was what I was told too.

I felt so embarrassed and dumb in front of the patient. But I still blame the previous nurse who told me that.

This is why I never rely on what another nurse tells me in report as fact. I always do my own checking/investigating as I too have been burned before by inaccurate information.

PauperRN

83 Posts

Being a nurse in itself was a grave. But we live and learn. On the nxt career train outta here

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