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.

I left a tourniquet on someone's forearm for about...30-45 minutes. Yup! It was the end of a really lousy day and I needed to grab some blood from a LOL before report. Got the tubes I needed and gave report to the night nurse and went home. The next morning I came back and the nurse said, "just a heads up someone left a tourniquet on her arm, luckily it wasn't tied tightly and it didn't occlude blood flow, just be careful." It still haunts me to this day. After drawing blood or starting an IV I've been known to check and recheck 3-4 times. It could have been so much worse...

I inserted an NG tube and checked for proper placement, both by auscultation and pH. Both confirmed it was in the stomach. The doc ordered the NG to be hooked to suction, so immediately after checking placement I hooked it to the suction. I completely forgot that before anything happens with the NG tube it has to be confirmed by x-ray for proper placement! Luckily someone else caught it after it had only been hooked to suction for about 30 min. I felt so stupid, but was relieved when the x-ray confirmed it was in the stomach. I'll never make that mistake again!

Specializes in Pediatric/Adolescent, Med-Surg.
I inserted an NG tube and checked for proper placement both by auscultation and pH. Both confirmed it was in the stomach. The doc ordered the NG to be hooked to suction, so immediately after checking placement I hooked it to the suction. I completely forgot that before anything happens with the NG tube it has to be confirmed by x-ray for proper placement! Luckily someone else caught it after it had only been hooked to suction for about 30 min. I felt so stupid, but was relieved when the x-ray confirmed it was in the stomach. I'll never make that mistake again![/quote']

I have never worked someplace where x-ray is necessary for placement for suction. The x-ray is essential if you are administering feeds, but I don't see the point for suction

Specializes in Telemetry, OB, NICU.

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.

Specializes in Med/Surg,Cardiac.

Not really a big mistake but I have had a morphine carpuject explode. I didn't even inject air into it so I'm not sure what happened. I did get morphine all over my shoes. Lol.

~ No One Can Make You Feel Inferior Without Your Consent -Eleanor Roosevelt ~

Many facilities have unregulated care providers giving medication including insulin. NO nurse on staff!!!! All about the $$$$

Specializes in Emergency/Cath Lab.

Biggest I have seen was hanging a bag of Heparin instead of NS bolus...

Specializes in Trauma Surgery, Nursing Management.

Oh, this is SOOOO embarrassing...but here goes:

I was a brand new nurse, working on the gyn/onc unit. I was three weeks out of my orientation, but still sought out the advice of senior nurses. I was working the night shift, and my pt asked for some Benadryl. She was POD 1 s/p partial colectomy from a SBO, and had an NG tube. She was young, well mannered, and surprisingly, had makeup on and every hair in place. Her nails and toenails were carefully manicured, and she was wearing luxurious silk pajamas. Yeah. At 2330, she still looked like a model!

I brought her the meds and a cup of water. She sits up in the bed and takes the Benadryl PO...and starts to gag. The gelatin coating on the pill stuck to her tube, and she couldn't get it down. Panicking, I hit the call button. My charge nurse comes rushing into the room, and I explain what happened.

"I don't (gag) understand what (gag) is so (gag) difficult (cough) about giving (gag) me a bleeping (cough, gag) pill!" my patient says.

My charge nurse sits beside my patient, and encourages her to drink more water to dissolve the pill.

"Canes is a new nurse, and didn't realize that she had to give you the pill through your ng tube. We'll get through this, though," she says reassuringly to my patient.

"Shouldn't that (gag) be in my (gag) chart?!?" the patient asks, throwing darts at me with her eyes.

"Yes, it is. But everyone makes mistakes, and she's learning. I seriously doubt she will forget this mistake, and will most definitely learn from it," my charge nurse says. She throws double darts at me with her eyes.

I pipe up, "Ms. X, I am so very sorry. It won't happen again."

"Have some more water," my charge nurse says.

The pill finally breaks free, and the patient lays back in the bed. I fluff her pillows, draw her blanket up around her, and fuss over her for a few more minutes. I ask her if she needs anything else before I leave.

"Yeah," she says. I need a competent nurse!"

I walk out to the nurses station to find my charge nurse sipping on a Diet Coke and laughing with the nursing assistant. Obviously, I am the butt of the joke.

"Canes, come over here," my charge nurse says.

My lip is already trembling and I am trying my best to hold the deluge of tears at bay. I feel like a total failure: the Forrest Gump of Nurses. Blinking rapidly, I walk over to my charge nurse and sit beside her.

Giving me a playful slap on my thigh, my charge nurse tells me that everything is fine, but that I dodged a bullet. Becoming serious, she says, "You forgot to check your 5 R's, Canes. ROUTE! I think you know at this point that your route was incorrect. Learn from this, and don't make the same mistake, k?"

Gracefully, she didn't tell me that this pt was a VIP...the CEO's wife!

I will never forget that experience, and always think about that scenario when I feel that I am not looking at every single angle when treating patients.

Anyone else extubate a patient by accident when turning or transferring? Luckily my difficult airway patient was reintubated without further incident.

Once I missed an important assessment finding. I should have been more thorough. Next thing I am facing a lawyer and my manager. I am still not over that one.

Specializes in Trauma Surgery, Nursing Management.

RNP-

I have not done this myself, but I have witnessed it. One of the scariest things I have ever seen in my nursing career!

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Anyone else extubate a patient by accident when turning or transferring? Luckily my difficult airway patient was reintubated without further incident.

Once I missed an important assessment finding. I should have been more thorough. Next thing I am facing a lawyer and my manager. I am still not over that one.

Extubate someone?...... I cut the ETT tube! :banghead: This was years ago...but I remember every single moment vividly!!!!!!!!!

We had a difficult intubation...a real mess....the patient finally got intubated under scope. Needless to say it was a mess.....their mouth was bleeding....the tape looked "messy and bloody" Soooo.....being the good nurse I am I had to have nice clean ETT tape...as we were doing the patients care we (my co worker and I) felt it necessary to re-tape the ETT. I was a pro at this and my patients always looked neat and clean with immaculate fresh beds. As I was trying to removed the tangled tape mess in the patient beard.....I needed to just take a "little snip" to clear the tube and oops! :eek: I snipped the pilot tip that kept the balloon tip inflated......

HOLY :poop:!!!!!!!!! This doc was going to KILL ME!!!!!!!!!! I quickly "fixed" the tube with an angio cath tegaderm and a syringe...I wanted to DIE....:angrybird9:

When I called the MD I made him yell at me first and made him say nasty thing to get it out of his system because I had been incredibly stupid......he was so thankful the patient wasn't dead and the ETT technically still in he didn't yell too much...but I NEVER lived it down....to this very day he remembers (and so do I):nailbiting:

I did the same thing in an ICU...just trying to make things neat and clean, and snipped the inflation channel on the trach tube. Ran quick like a bunny and took a 16ga needle, cut it off to about 3/4" with my trusty 6" scissors, jammed that sucker in there, put on a stopcock, and blew up the balloon and closed the port. The doc didn't even want to change it, since it was secure and functional, but I persuaded him that perhaps it would be a good idea.

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