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.

Specializes in NICU.

A patient was allergic to the skin cleaning prep wipes we use and I neglected to tell the nurse coming on. The patient needed blood and an IV was started by another nurse--using the wipes. Thank goodness there was no reaction. There was a sign in the room about it and an allergy band on and a note in the chart...but it's super rare to be allergic to these wipes and had I been in that nurse's shoes, I can't say for sure that I wouldn't have caught the mistake.

Felt so horrible about it...especially because I wasn't the one reprimanded about it. Technically, yes I wasn't the one who did the actual error, but it really was my responsibility to tell that nurse, especially since it's so rare. I apologized to the nurse profusely.

CHECK YOUR ALLERGIES!

Specializes in Public Health, TB.

Early in one of my first clinicals I was removing tape from a patient's arm. I was unfamiliar with the appearance or fragility of "prednisone" skin. I caused an ugly skin tear when I removed the tape too quickly. I wanted to quit right there and then.

I once gave an injection, back when I was still intimidated by older nurses and Doctors, And I was told to give a Morphine injection, when I went to check the chart for myself for drug allergies, I was barked at by the Doctors. I foolishly followed orders, and yes- the patient was alergic to Morphine.

I never, NEVER made that mistake again. I lost my bashfulness immediatly.

The patient was alright, thank God.

Specializes in ER, Pediatric Transplant, PICU.

I didn't realize as a new grad just how much doctors DONT check allergies. In the ER, they throw around orders and dont think twice about it. On several, several occations I have already gotten the meds and thank goodness I asked allergies.

Nothing is more terrible than that sinking feeling after you realize you've made a med error. Even a "small" one. Ugh. Makes me sick just to think about it!

Becoming a nurse was the worst mistake of my life!!!! I get verbally abused every day by either coworkers,patients or family of. Sick of it. Sould have went into interior design.....

Specializes in ICU.

Worst mistake..... Putting a demerol syringe in the pca instead of the morphine that was ordered when I changed it. Thank god he wasn't allergic, it he was getting the wrong drug and highly undermedicated. The doc caught it, was a cool doc, and we wrote an incident report.From then on I look up brand names, rather than generics ( too much alike) and don't rush and quadruple check!

Great topic!

My first error was for a patient that was on two syringes of antibiotics every 4 hours. For my entire shift I gave only one syringe per dose:/

I also crushed medication that said non crushable, I asked the doc who was there if he wanted to change the medication, and he said to just crush it. I learned later that pharmacy had a crushable version that I should have called and ordered.

My daughter has been on the receiving end of medication mistakes, once we were in the doctors office getting her allergy results. The doctor came in and explained she was allergic to eggs, milk, cheese and a multitude of other things, then said "you want to get her flu shot today while youre here?" I said sure (this was prenursing, had no clue the egg-allergy reaction from the flu shot). So she got the flu shot and had a major skin reaction that caused her throat/tongue to swell as well as hives all over her entire body.

The she had to have a medication called albenza, the doctor knows her allergies and still prescribed it (it has an egg allergy alert also) and they also dosed her with an adult dose (over 4 times the max amount for her weight)....again major allergic reaction. Needless to say I got a different pediatrician that day. This was also pre-nursing. Now that I know a little about medication and dosages I meticulously check everything I give to her everytime. Dont blindly think these doctors always get the doses right!!

Specializes in Med/Surg, Dialysis.

When I was a brand new nurse and still w/ a preceptor, I misread a MAR and gave 25 units of regular insulin instead of the ordered 25 units of long-acting insulin. My preceptor was mad, I called the doctor and had to give the pt a dextrose IV and do hourly finger sticks. I was pretty embarrassed but I think my preceptor could have been a little more involved, she was in space that day!!! Since then, I always triple check insulin dosing!!

Specializes in Trauma-Surgical, Case Management, Clinic.
When I was a brand new nurse and still w/ a preceptor, I misread a MAR and gave 25 units of regular insulin instead of the ordered 25 units of long-acting insulin. My preceptor was mad, I called the doctor and had to give the pt a dextrose IV and do hourly finger sticks. I was pretty embarrassed but I think my preceptor could have been a little more involved, she was in space that day!!! Since then, I always triple check insulin dosing!!

Just wondering if your facility has a policy that insulin and other high alert meds have to be verified by 2 nurses? I had a near miss with insulin one time. It was night shift and I was going to give sliding scale insulin based on the day time scale. When checking it with another nurse it was brought to my attention that the pt was not suppose to get any insulin based on the night sliding scale. Mistakes are so easy to make. I usually triple check my meds but somehow in this case I was reading the MAR wrong, didn't scroll down far enough to see that there was another sliding scale below the daytime one.

Specializes in 4.

Thank you so much for this topic. It reminds me that I am not alone & none of us are perfect (especially the one's who can't admit it).

Specializes in Reproductive & Public Health.

I will never forget my first med error. I was caring for a mom in labor with her 3rd baby. GBS positive. I gave penicillin, even though it was BRIGHT red on her chart, labeled everywhere that she was allergic. Thank god, she was absolutely fine with no reaction. It scared the bananas out of me.

This isn't a med error per se, but I gave a kid a water bolus through his gtube with the extension clamped and the med port open. Water everywhere, all over his freshly changed clothes, the linens etc. I gave like 50cc before I noticed what was going on.

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