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.

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!

Specializes in Oncology, Med-Surg.

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.

Specializes in NICU, ICU, PICU, Academia.

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!

Specializes in ICU/CCU/CVICU.

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.

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.

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!

I just found out that we are not allowed to start an IV at any of our clinical sites (I think because of insurance reasons). We do have to know the mechanisms of how to do it, but the only practice we get is in lab next week on a fake arm that bleeds. I think it's a little crazy that we won't be able to start on IV on a real person until we are licensed RNs.

Practice on each other! That is what they do at the school where I work. They practice their blood draws on each other (and anyone they can sucker into it!) I always volunteer because I figure it is just a simple stick, usually butterfly, which they miss half of the time anyway. Newbies, gotta love em!

I learned to speak up if I don't feel the assignment is safe. I got into a situation where I was new and I was scared of the assignment at report time. But I thought, I can handle this, it's a good learning experience right? Wrong. I made a mistake that did not harm anyone long-term but it was because I was overwhelmed and feeling anxious and rushing. There is a fine line between being out of my comfort zone but I can make it fly, and not being safe because I can't handle all the tasks and have time to slow down, think about what I'm doing, and keep a good eye on the patient to watch for changes. I am now very free to tell my charge nurse my feelings and ask for help. Last night was one of those nights that at report time I knew it was going to be tough as I had two very touchy patients with lots and lots of tasks to complete that it was impossible. I spoke up and another nurse was assigned to take over one of my patients for part of the shift-- she had an open bed still. Later on things had settled down and I took the patient back into my care while she took the new admit.

Is it just me, or does it appear that you can give just about any dose of Coumadin, and the INRs go all over the place, almost as though they have a life of their own? A crapshoot, even? It must the most unpredictable med out there.

Specializes in Pediatrics, Emergency, Trauma.
I learned to speak up if I don't feel the assignment is safe. I got into a situation where I was new and I was scared of the assignment at report time. But I thought I can handle this, it's a good learning experience right? Wrong. I made a mistake that did not harm anyone long-term but it was because I was overwhelmed and feeling anxious and rushing. There is a fine line between being out of my comfort zone but I can make it fly, and not being safe because I can't handle all the tasks and have time to slow down, think about what I'm doing, and keep a good eye on the patient to watch for changes. I am now very free to tell my charge nurse my feelings and ask for help. Last night was one of those nights that at report time I knew it was going to be tough as I had two very touchy patients with lots and lots of tasks to complete that it was impossible. I spoke up and another nurse was assigned to take over one of my patients for part of the shift-- she had an open bed still. Later on things had settled down and I took the patient back into my care while she took the new admit.[/quote']

^Learning this as well...again, as a new grad (from being an well-rounded LPN)

Had a similar "come to Jesus" meeting with me orientation coordinator. It is a HUGE learning curve, this CC machine, and I knew that coming in and was vocal about that. Guess I wasn't vocal enough, or my communication on my part was more to the different culture of the unit and hospital, in addition of what you are experiencing above. This is one of the few places I worked where it is a positive work environment-SO NOT used to that! Any-who...I spoke up well enough for her to decide "I haven't given up on you yet." Well I don't give up on myself lol..but I'm working at it...from here on out, I'm MAKING it CLEAR... for the sake of safety,my pts and my SANITY!! We will get there! ;)

Biggest mistake I ever made as a new nurse is with IV fluids and I saw nurses that started behind me, make this mistake over and over again. It could have been fatal, but luckily the odds were with me that night.

They say you should always do hourly checks of your IV rates (to make sure the same rate is on the pump), which I ALWAYS did.

However, when fluids are changed out by shift, what I never thought to do, is follow the line from the bag through the pump slot to make sure the IV that I thought was running at 25/ml an hour was the IV I WANTED to run at 25/ml an hour.

I accidently transposed two fluids when I changed the bags and lines out and didn't discover this until much later in the shift.

I can tell you this..I never made that mistake again.

Specializes in PDN; Burn; Phone triage.

eedit

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