What's the biggest mistake you've ever made as a nurse? What did you learn from it? What's the biggest mistake you've ever made as a nurse? What did you learn from it? - pg.6 | allnurses

What's the biggest mistake you've ever made as a nurse? What did you learn from it? - page 6

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... Read More

  1. Visit  SleeepyRN profile page
    #65 0
    I had a resident on 3 anti seizure meds. One med, I didn't know it wasnt for pain but for seizures(it was in narc box). Brand new nurse, overloaded with residents, decided to give his meds last. Shamefully I hadn't looked up the reason for the med. He got it, but like an hour late! I can't believe I didn't look it up in the drug book. I felt so bad when I finally did look it up.
  2. Visit  SoCalGalRN profile page
    #66 1
    Quote from Nugget
    Mine happened just last night! Hence the reason I searched "mistakes" on here as soon as I came home, crying.
    These happened with the same patient:
    1. Patient had order for lorazepam 1-2 mg IV for seizures. I read the order as IM and gave as such. Realized that this morning, and also realized that I wouldn't have been able to give it IV anyway, because I am not a critical care RN. Called the MD on-call who was unphased and said "Oh, okay! Whatever" haha.

    2. Also this morning, realized my patient's foley cath output was ohhhh about 100mL overnight, and I was so preoccupied with the 1 million other tubes coming out of her, I didn't even realize.

    I actually want to quit and hide in a hole. 1st year of nursing is sucking.
    You can't give lorazepam IVP? We give it all the time on MedSurg.
  3. Visit  eatmysoxRN profile page
    #67 1
    Quote from SoCalGalRN

    You can't give lorazepam IVP? We give it all the time on MedSurg.
    That's what I was thinking. I am surprised by these things I read on here and wonder what caused these policies to be placed. Probably things that belong in this thread.

    ~ No One Can Make You Feel Inferior Without Your Consent -Eleanor Roosevelt ~
  4. Visit  rn undisclosed name profile page
    #68 0
    Quote from SoCalGalRN
    You can't give lorazepam IVP? We give it all the time on MedSurg.
    I've worked at a couple of facilities and was always able to give lorazepam ivp. Never given it IM. Haldol is another story. I worked at a facility where only ICU nurses could give haldol ivp d/t prolongation of QT if administered too quickly. We could give IVPB.

    Yeah it sucks when you make a medication error. I've made a couple in my years. I was still a new nurse on orientation and heplocked a dialysis catheter on a pt who was HIT +. I let the nephrologist know. They wondered why I called about that. Likely none of it got to them systemically.

    Just a few months ago I had 5 patients and they were all on some sort of drip (I was the only nurse with patients on drips that day and I got them all). I started a bumex drip and I am not as familiar with that as other medications. I programmed the pump incorrectly. I believe I was supposed to have it going at 3 ml/hr and had it going for 3 mg/hr (don't quote me on those numbers). I was used to lasix gtt's which are 1 mg = 1 mL. The nurse on the next shift didn't catch it either and the nurse on the following shift caught it 6 hours into her shift. I apologized to the nephrologist the next day and he told me not to worry about it. The particular nurse who assigned this load to me does a horrible job of making assignments. I've complained and my manager blows me off about it. My educator talked to me about the mistake. I told her it was not a good day for me on the unit and they shouldn't assign all the drips to 1 nurse when there are 7 nurses on the unit. That wasn't an acceptable excuse.

    Unfortunately mistakes happen. We're only human! We try our best and would never intentionally harm someone.
    Last edit by rn undisclosed name on Apr 4, '13 : Reason: wording error
  5. Visit  turnforthenurse profile page
    #69 1
    Patient was supposed to get 3 units of Novolog but ended up getting 7 units because my CNA mixed up the blood sugars and told me the wrong one. Patient was okay and actually their sugar ended up being even higher the second time around. Moral of the story: now I make sure that glucometer gets docked so I can actually see the blood sugar results upload into the computer and into each patient's individual chart.

    This was a mistake I made somewhat recently. MD ordered a unit of blood to be given. Apparently this order was put in at 12:30 and was missed by the dayshift nurse AND me. Patient was to go for an amputation the next morning and the surgeon calls me in the AM and asks,
    "Did Doctor X order any blood?"
    *frantically searching through the patient's chart and looking at all of the patient's active orders* "No, sir, I do not see an order here."
    "Oh, okay then. I will call Doctor X. Thank you."

    A few minutes later one of the CNAs (and I don't know why she was the one to tell me or why she spoke to the doctor) came up to me and said, "umm just so you know, the patient's surgery got cancelled and the doctor called and was ****** and he wants you to call him back NOW." I just wanted to cry, crawl under a rock and be left alone. I called the surgeon, and surprisingly I didn't get chewed out, they just told me the surgery will be post-poned until tomorrow and the patient will just get the unit of blood during their scheduled HD today.

    I spoke to the dayshift charge and told them what happened, they said "well whoever it was before you should have been the one to administer the blood" but I told them that since it wasn't completed on their shift, it falls on my shift and it became my responsibility.

    So what happened? The MD ordered 1 unit to be transfused but wrote that in the patient's hemodialysis orders. We have computer charting at work and we have been told by management not to start the HD orders; only the dialysis RN is supposed to do that. So, naturally, I ignore them. I just see "Hemodialysis" in the planned state. When I looked at the plan, there was the order: "transfuse 1 unit of PRBCs." I could not have initiated that order without initiating the entire HD plan. Of course, I didn't see this until after I had learned the surgery was cancelled and that the MD indeed ordered a transfusion.

    Regardless, I told the dayshift charge I would take full responsibility for whatever happened...I told the patient and they were very upset with me, as they should have been. Anyway, the patient went for surgery the following day and everything turned out to be A-OK. Thank goodness.
  6. Visit  limaRN profile page
    #70 1
    So I feel like mine are so much worse than these! But here goes: I had a post-op CABG pt and have 20 meq of kcl via the central line. I got distracted and programmed the iv pump as an antibiotic and have the kcl at 100 ml/ hr when it was supposed to be given at 50ml/ hr. I realized it when the bag was almost empty. I did ask another nurse to double check it but they apparently missed it too. The pt was fine however. Not even a PVC worth if ectopy!

    The next one is a little more embarrassing. I had a pt that had a sternal wound infection being irrigated. I was trying to change the dressing around the tiny irrigation catheter and accidentally slit the catheter. The surgeon was ****** and yelled at me in front of everyone. The pt had to go back to the OR and have the catheter replaced. I felt like such a loser that day.
  7. Visit  nurseprnRN profile page
    #71 0
    Quote from limaRN
    So I feel like mine are so much worse than these! But here goes: I had a post-op CABG pt and have 20 meq of kcl via the central line. I got distracted and programmed the iv pump as an antibiotic and have the kcl at 100 ml/ hr when it was supposed to be given at 50ml/ hr. I realized it when the bag was almost empty. I did ask another nurse to double check it but they apparently missed it too. The pt was fine however. Not even a PVC worth if ectopy!

    The next one is a little more embarrassing. I had a pt that had a sternal wound infection being irrigated. I was trying to change the dressing around the tiny irrigation catheter and accidentally slit the catheter. The surgeon was ****** and yelled at me in front of everyone. The pt had to go back to the OR and have the catheter replaced. I felt like such a loser that day.

    Um, people have PVCs when their K+s are LOW, not elevated. And you can give 20mEq in an hour if you have to.

    I cut a trach balloon inflation channel once; I was able to make a really fast repair by cutting a 15ga needle off about 1/2 inc from the hub and jamming it into the residual tube, then putting on a stopcock and inflating with a syringe there. Idiotic, but the doc just changed it without comment.
  8. Visit  SwansonRN profile page
    #72 0
    Quote from limaRN
    So I feel like mine are so much worse than these! But here goes: I had a post-op CABG pt and have 20 meq of kcl via the central line. I got distracted and programmed the iv pump as an antibiotic and have the kcl at 100 ml/ hr when it was supposed to be given at 50ml/ hr. I realized it when the bag was almost empty. I did ask another nurse to double check it but they apparently missed it too. The pt was fine however. Not even a PVC worth if ectopy!

    The next one is a little more embarrassing. I had a pt that had a sternal wound infection being irrigated. I was trying to change the dressing around the tiny irrigation catheter and accidentally slit the catheter. The surgeon was ****** and yelled at me in front of everyone. The pt had to go back to the OR and have the catheter replaced. I felt like such a loser that day.
    Agreed with the previous post, a common EKG change with hyperkalemia is peaked t waves. Then you'll see a widening of the PR interval and eventually you'll lose the P wave all together with a widening QRS complex. This is all with a K greater than 6 at least. I'm assuming if you were giving KCl the K was less than 4 and the patient had working kidneys. Plus, where I work we run 20mEqs in 100mL over an hour routinely. The only time we run it slower is if the patient doesn't have a central line. Basically what I'm trying to say is don't beat yourself up about that mistake!
  9. Visit  salvadordolly profile page
    #73 2
    I have been really lucky. Once I was working pool at a new hospital and I mixed up bed A and B and gave the one patient thiamine and lisinopril that were meant for the other. I got the feeling something was wrong, so I double checked and discovered my error. My heart was beating really fast. We checked the guy's BP all noc, no problem.
    Another time, I was in charge and had a full load of patients. I was drawing Dig for a patient in A-fib and a resident kept talking to me about other patients while I was doing it. The dose was 0.125 and I drew up the whole vial of 0.5, but I realized it just before I gave it to her, so no biggie, but my heart was beating fast again. I learned not to let other people disrupt me so much while I was doing meds.
    As a new grad, I made some typical mistakes. I let someone talk me into doing a double at a private duty quad with a vent. I checked her foley and it had the right amount of urine for one shift, but not 2 shifts. Her foley tubing was bent and she had spinal dysreflexia because of it. Luckily, I caught it when she just had the "sweats" and no other sx. I learned not to let others push me into things I know I can't do.
    Another new grad mistake I made was writing down a verbal order from another nurse. It was wrong, and I ended up being written up for it. I did write it. I learned never to write orders for another person.
    Another new grad mistake I made was allowing a family member yap at me while I was trying to draw blood from a CVL on an HIV pos patient. I ended up sticking my finger with a 16 g needle from the patient and it was quite deep and drew my blood (this was before needleless systems were commonplace). That was a nerve-wracking first year, waiting for all those HIV, Hep b and C tests! I learned to always ask visitors to step out while I do any procedure, even if the patient says it's okay.
  10. Visit  marycarney profile page
    #74 2
    Back when dinosaurs ruled the earth, I worked in an adult ICU. My patient had a swan- ganz as his only access, and had dopamine running in the distal port. His pressures and CO were getting better, and I weaned it as far down as I could. Called the doc and got an order to D/C. Stopped the dopamine and flushed the whole line with saline ---- rapidly! The guy's heart rate and BP skyrocketed, and he said "Yeah, so I'm feeling a little shaky....." It lasted a couple minutes - the longest 'couple minutes' of my whole life!
  11. Visit  limaRN profile page
    #75 0
    Quote from sarakjp

    Agreed with the previous post, a common EKG change with hyperkalemia is peaked t waves. Then you'll see a widening of the PR interval and eventually you'll lose the P wave all together with a widening QRS complex. This is all with a K greater than 6 at least. I'm assuming if you were giving KCl the K was less than 4 and the patient had working kidneys. Plus, where I work we run 20mEqs in 100mL over an hour routinely. The only time we run it slower is if the patient doesn't have a central line. Basically what I'm trying to say is don't beat yourself up about that mistake!
    To be clear I gave the 20 meq of k over about 1/2 hour and was surprised that nothing happened. Yes you are correct the pt would not have pvc's I was wrong about that. I was surprised that their heart did not stop/ they did not have rhythm changes from getting kcl too fast. I always make an RN go and double check my drips now and if they don't really look at it I get someone else. It's easy to make a mistake when things are moving fast.
  12. Visit  aflower1325 profile page
    #76 1
    Even those who are not nurses or in the medical profession can at least be advocates to their own healthcare. At the very very least, check the prescriptions you receive from the pharmacy against the description that comes with the information packet you get with it. If you have never taken it before, speak with the pharmacist when they ask if you would like to. And if you are chronically ill and know your regimen, speak up about something that is not being done as it should be. Sometimes patients know more about their bodies than health professionals do.
  13. Visit  aflower1325 profile page
    #77 0
    Quote from Nursetastic
    I accidentally attached Pitocin instead of LR directly to the hub of a triple codon and opened it wide; the lines were clearly labeled, I was just chatting with mom and not paying attention. The patient may have gotten, at max, 2 cc's before I caught the mistake. The patient had a 10 minute tetanic contraction. I put mom on a mask and stayed at bedside. Thankfully the baby's heart rate stayed stable and mom was ok. I explained exactly what happened and mom revealed she is a RN in a neighboring city. She and I ended up turning it into a learning opportunity. She was amazing but I still have not recovered! The midwife, unit director, and charge nurse were all amazing actually. My mistake caused a change in line label sizes and colors to draw more attention to high risk drugs.

    Fantastic to see a precarious situation turn into a learning experience for EVERYONE. I am glad it lead to changes to further protect the patients from mistakes and the staff from making them! Sorry it happened but great to hear the positive changes that proceeded it!

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