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

[Mini-Murse]

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.

[june2009]

I hung heparin on a pt. Who just came back from having a heart Cath. Could have been bad but another nurse came in to help me get the pt. Settled and noticed what I did. She only got about 2 minutes worth of heparin.

[Mn nurse 22]

Ok so I am working in LTC and was training a new nurse. She had trained several days and was ready to pass meds on her own with just supervision. She was doing well until she told me "I think I gave meds to the wrong patient. I find out she gave bed A's meds to bed B. I knew that bed A was on a lot of seizure meds and blood pressure meds so I panicked. I ran down the hall to grab our DON and then learned one of the most important lessons about giving the wrong meds. CHECK THE PATIENT'S ALLERGIES!!! The DON was good enough to help walk me through the procedure. After checking allergies I called the doctor. After giving him a frantic report he assured me that she would be fine but wanted us to check her Blood Pressure hourly and push fluids. He then asked me "are you OK?" Bless his dear soul, he could tell my voice was shaking and I was a wreck. I then had to call her family and update them which was also hard because they were longtime family friends.

Even at 101 years old she was fine and lived until she was 103, but I won't forget that feeling.

I also worked in a facility that had medication aids who weren't even trained as CNAs. One lady gave a patient her "own" dose of insulin instead of the patient's sliding scale and had the audacity to tell me "well that is the dose I would give myself". I didn't stay there much longer because it just wasn't safe. She wasn't even fired and I had to fight to get her removed from passing meds after so many errors.

[Christy1019, ASN, RN]

Ok so I am working in LTC and was training a new nurse. She had trained several days and was ready to pass meds on her own with just supervision. She was doing well until she told me "I think I gave meds to the wrong patient. I find out she gave bed A's meds to bed B. I knew that bed A was on a lot of seizure meds and blood pressure meds so I panicked. I ran down the hall to grab our DON and then learned one of the most important lessons about giving the wrong meds. CHECK THE PATIENT'S ALLERGIES!!! The DON was good enough to help walk me through the procedure. After checking allergies I called the doctor. After giving him a frantic report he assured me that she would be fine but wanted us to check her Blood Pressure hourly and push fluids. He then asked me "are you OK?" Bless his dear soul, he could tell my voice was shaking and I was a wreck. I then had to call her family and update them which was also hard because they were longtime family friends.

Even at 101 years old she was fine and lived until she was 103, but I won't forget that feeling.

I also worked in a facility that had medication aids who weren't even trained as CNAs. One lady gave a patient her "own" dose of insulin instead of the patient's sliding scale and had the audacity to tell me "well that is the dose I would give myself". I didn't stay there much longer because it just wasn't safe. She wasn't even fired and I had to fight to get her removed from passing meds after so many errors.

I bet with those seizure meds on board that patient slept well that night! Lol

[Bezoars]

Okay, I have made insignificant errors along the way... but here's the worst. I was helping out our church by being the camp nurse for kid's camp one year. Lots of kids getting allergy meds and stuff like that. Rural setting, nothing computerized, everything on cards, etc. We had one on several seisure meds and one diabetic (who was very attentive to her insulin). Anyway, one night I was passing meds after chapel and my blond seisure med girl comes up to the desk and I make my first mistake. "Oh are you Abby such-and-such here to get your meds?". She says "yes" tentatively and I count out and hand her her cup of seisure meds. It wasn't the right girl. This girl looked very similar to her but it wasn't her. Turns out, this girl was just coming up to get a cough drop, but she was shy and just answered yes to my questions. Fifteen min later, the REAL girl comes up to get her seisure meds and my eyes went wide I raced to her info sheet to sort it out and look for allergies. I then went to find the girl I mistakenly gave meds too. She was tearful and feeling bad by now. I velcroed her to my side as we went to find the director and tell him what happened. He was nervous. I had to call her dad and explain the situation. We took her to the ER where they observed her overnight and then released her. Here's the worst part... nobody even came to see her at the ER. She was living with a dad that didn't take much interest in her and was happy to get her out of his hair for a week each Summer. He says "call me if it's anything serious". It was a HOT MESS and I will never get over it. Ugh. It all ended well, but it was scary.

[calivianya, BSN, RN]

Okay, I have made insignificant errors along the way... but here's the worst. I was helping out our church by being the camp nurse for kid's camp one year. Lots of kids getting allergy meds and stuff like that. Rural setting, nothing computerized, everything on cards, etc. We had one on several seisure meds and one diabetic (who was very attentive to her insulin). Anyway, one night I was passing meds after chapel and my blond seisure med girl comes up to the desk and I make my first mistake. "Oh are you Abby such-and-such here to get your meds?". She says "yes" tentatively and I count out and hand her her cup of seisure meds. It wasn't the right girl. This girl looked very similar to her but it wasn't her. Turns out, this girl was just coming up to get a cough drop, but she was shy and just answered yes to my questions. Fifteen min later, the REAL girl comes up to get her seisure meds and my eyes went wide I raced to her info sheet to sort it out and look for allergies. I then went to find the girl I mistakenly gave meds too. She was tearful and feeling bad by now. I velcroed her to my side as we went to find the director and tell him what happened. He was nervous. I had to call her dad and explain the situation. We took her to the ER where they observed her overnight and then released her. Here's the worst part... nobody even came to see her at the ER. She was living with a dad that didn't take much interest in her and was happy to get her out of his hair for a week each Summer. He says "call me if it's anything serious". It was a HOT MESS and I will never get over it. Ugh. It all ended well, but it was scary.

You know... I have to say that I don't think that's your fault and that you can stop letting it hang over your head. I know it was scary, but you can't routinely expect patients to lie to you when you ask them who they are. It's not like kids at camps have identification bracelets on like patients do. You can't make sure they are being honest with you, and you did a great job fixing the problem. Kudos to you!

[heidi94]

Reading this thread is both reassuring and scary as a new nursing student....reassuring as I can see that everyone makes mistakes and scary that I know I'm bound to have plenty of moments in my future career where I'm gonna be terrified and kicking myself because I made an error.

I'm only in my 5th week of school and I've already had a mistake in clinicals that I keep thinking about/freaking out over. My 3 day in the hospital I gave a pt who was on thickened liquids only a drink of water. He turned a little red and coughed for a while but as far as I know he was fine....the Pct walked in on me when I was about to go tell the nurse he was coughing. Luckily she only chewed me out a little but and was actually pretty nice, saying "you learn from your mistakes" and telling me about a mistake she made. My preceptor didn't even really say anything, I don't think she was too mad but I couldn't really read her...Anyway I still feel terrible.

[heidi94]

Double post, sorry!

[KRVRN, BSN, RN]

Saline lock flushed with vecuronium. Our unit learned that there shouldn't be stock bottles of vecuronium and heparin flush in the same med fridge.

[canchaser530]

I'm still a new nurse and learning from my mistakes, but sometimes I feel like I'm the only one who makes mistakes. This post is great for boosting my confidence as I learn that we are all human! The first time I ever got in trouble with my manager was because a doctor told me over the phone that the patient would be having a laproscopic cholecystectomy the next day and to put that in the orders along with an order to get the consent. I put both of those orders in the chart, got the consent, and trying to do what I had learned, I went ahead and put in the order for the patient to be NPO after midnight for the procedure. Well several days later, when the patient is being discharged, I learn that the doctor was very upset and refusing to sign the patient's chart because he never gave orders for the patient to be NPO. True, he never gave that order, but the patient was having surgery, isn't that a given?! My manager informed me that if I ever did that again that I would be written up. Then she told me that next time I should just hold the breakfast tray, and not put the order in the computer. I was not the nurse for the next day, what if that nurse forgot.

My next mistake I got into trouble for was over labs. In this case the patient was a very hard stick, and it took 4 different nurses trying just to get an IV started on her the day before. The doctor ordered a couple of labs to be done on this day of my shift. I knew the patient was a hard stick, and I knew the patient would be going for dialysis later that day. So, I saved the labels for labs, and sent them with the dialysis nurse to be drawn there. Later in my shift I saw new lab results pop up on the screen, quickly glanced through them, then moved on. I assumed all of the labs were done after that, but never went in a really checked it good. The next day I received a call from my manager, on my day off, that the doctor was very upset and throwing a fit at the nurses station because the labs he had ordered were not done. I was told by my manager that the incident would be reported to administration, and never heard anything else after that.

[Karou]

I'm still a new nurse and learning from my mistakes, but sometimes I feel like I'm the only one who makes mistakes. This post is great for boosting my confidence as I learn that we are all human! The first time I ever got in trouble with my manager was because a doctor told me over the phone that the patient would be having a laproscopic cholecystectomy the next day and to put that in the orders along with an order to get the consent. I put both of those orders in the chart, got the consent, and trying to do what I had learned, I went ahead and put in the order for the patient to be NPO after midnight for the procedure. Well several days later, when the patient is being discharged, I learn that the doctor was very upset and refusing to sign the patient's chart because he never gave orders for the patient to be NPO. True, he never gave that order, but the patient was having surgery, isn't that a given?! My manager informed me that if I ever did that again that I would be written up. Then she told me that next time I should just hold the breakfast tray, and not put the order in the computer. I was not the nurse for the next day, what if that nurse forgot.

t.

Really?? I work med-surg and we put NPO after midnight orders in all the time for surgical patients if the physician forgets. If I know a patient is going for a lap chole at 08:00 and I am the night shift nurse, I won't be around to make sure the breakfast tray gets held. Dietary delivers even if there is an NPO sign on the door sometimes. If that patient were to have eaten, the surgery would have ended up delayed and gotten that surgeons schedule all out of wack. Would he have been happy then?

There are exceptions. For example, if the surgery won't be until afternoon the next day, and the surgeon didn't make the diet orders clear, I will call to clarify. What time was your patients surgery?

Once I had a 20 year old female AOx4 patient scheduled for hand surgery at 08:00 the next day. I made sure consent was on the chart, informed her of her NPO status after midnight, put a sign outside the door, wrote it on her whiteboard, ect...

I did not make sure there was an order for NPO. Dietary delivered breakfast, she ate, and the surgeon was livid with me. Day shift pointed out that he never put the order in, but the mistake was ultimately mine. Patients surgery ended up delayed and I heard about it when I returned that night. Lesson learned.

When in doubt, call. And after surgery always make sure the diet order is correct. I have heard of patients. NPO for days after surg because the physician forgot to write an order to advance the diet. But in your situation I fail to understand why the surgeon is making such a fuss. Did he WANT her to eat? Anesthesia will sometimes refuse patients who have not been NPO, even if the surgeon wants to proceed.

Had this happen in a situation where the pt came in with a severe hand injury (again with the hands!). I forget the details but basically he had been in prison, was out on some kind of weekend pass, and was going to have to go back on the next Monday. He had eaten shortly before the injury earlier that day, surgeon wanted to proceed, anesthesia refused and stated the surgery was not emergent or life threatening and the risks were not outweighs by the benefit. Surgeon wasn't happy, but patient did have surgery the next day.

Your surgeon sounds ridiculous. Unless there is more to the story, that's just absurd.

As for the labs...well yes, that's on you. I would have made sure to chart that the patient was a difficult stick, that dialysis agreed to draw the labs, and that I sent the labels with the patient. Then it's your responsibility to follow up that it did get done.

[Karou]

I have made many mistakes, but one of my more recent ones really stands out in my mind.

The mistake involved a beta blocker and a tachy surgical patient. Patient was to go for lap chole in the morning, had been on the unit for four hours when my shift started. Day shift never finished his admission and I was slammed with two admissions on my shift back to back. I didn't have time to complete his. He was tachycardic and I called the doctor, patient was febrile, so we thought that was why. HR never normalized even when fever came down. Hmm. Called doc again. Is he on any cardiac meds? I check the MAR...Nope. The doctor figured my rectal temp reading was off. Orders to continue to monitor. I was nervous, because unexplained tachycardia always makes me nervous. Sent patient to pre-op, informed them of the above. Ten minutes later I get a call that the pt had told them he had missed his beta blocker the day before. My face fell. I never verified his home medications. I never even asked! I was so upset with myself. All those interventions and conversations with the doctor, and I had never even thought to ask if he was on any other medications.

BIG lesson learned. Now, even if I am crunched for time, I always verify home meds, even if I don't have time to do the rest of the admission. And if something comes up, I ask my patients again what they take at home. Even if someone else already verified.

[Lioness333]

Becoming a nurse. What I learned from it was that it was an extension of co-dependency learned in childhood, the whole thing that took me away from my desired path. Fortunately I don't see my age as a limiting factor, and I'm returning to what I always wanted, and that surely has nothing to do with being a punching bag for everyone else.