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 Critical Care, ED, Cath lab, CTPAC,Trauma.

I canulated the rest of the tubing with an angio and did the same thing...used a stopcock...great minds...LOL

Specializes in Med-Surg.

Not using common sense. (1. Bragging on facebook about starting a cool IV, then having a coworker see it and try to get me in trouble.. 2. Being facebook friends with a frequent-flyer patient who ended up being somewhat crazy.. 3. Hanging IVF for a family member of mine and not knowing it breached HIPPA and then I ended up getting suspended, even though the patient's nurse was busy and he needed some fluids and he said, Please make this thing stop beeping.. didn't even think about it.) Thank God I finally got some common sense!

Specializes in Oncology, Med-Surg, Nursery.

Gave too much Synthroid IVP when working Med-Surg. Had to reconstitute medication and draw it up. Drew up too much. Called the doc, who acted like he seriously didn't know WHY I was calling him, but I was scared to death my patient was going to keel over instantly. :dead:

Thankfully, patient was 100% fine. I think *I* suffered more than anyone over that what with the cold sweat I broke out into upon discovering my mistake and the heart palpitations that followed, LOL.

Specializes in ICU.

It's nice to see that everyone makes mistakes. :)

I made one during my preceptorship. It was not uncommon on this floor for nurses to really help each other out - give so and so some insulin for me, draw up some insulin for me, can you change a rate on X, etc. Well. I told my preceptor what the patient's CBG was and she volunteered to go draw up some insulin. Key word: some. I think she had said at some point that she had drawn up 10 units of insulin, but I was thinking about something else and it just went in one ear and out the other. The patient only needed 2 units, but it was pretty common on the floor for a helping nurse to draw up maybe 10 or so units so the person at the bedside who was tied up could waste the rest in the sink and then give an appropriate amount. In my absent-mindedness I did not look at the syringe other than to hold it, assuming my preceptor had checked the MAR and drawn up the correct amount, and did not waste any of the insulin in the sink but instead gave the full 10 units to the patient. :unsure:

I got that feeling that something wasn't quite right immediately after I gave it, asked my preceptor how many units she'd drawn up, and got that funny feeling that ran through my whole chest and felt like someone was applying an ice pack to my sternum. Fortunately, the guy was on continuous enteral feedings and I checked the CBG pretty often and his never dropped below 100. In fact, that was one of the first times his blood sugar had been under 200, so maybe the sliding scale needed to be adjusted, or the feed formula needed to be adjusted, or something. Either way, he was fine, and I learned that if anyone else hands me anything that I've asked them to bring, should the occasion arise, that I should NOT trust that they got it right and should definitely check the med again myself before giving it. I will remember that awful ice cold feeling forever, and I hope I never feel it again!

Not a SERIOUS nursing mistake, but def embarassing...

Dont ever assume somebody is the father or son or whatever. ALWAYS ask how they are related. Some of my most embarassing moments is when I say something about "your dad" and the patient says,"um, that's my boyfriend"... or whatever.

SOOOOOO want to put my foot in my mouth!

HAHAHAHAHA I've done that several times myself! Talk about hopping out of the room cause I sure stuck my foot in my mouth!!

Specializes in Psychiatry.
i worked on a locked psych dept. and quickly learned three lessons:

1. never wear a necklace, earrings, etc. to work.

2. never turn your back on a patient, mo matter how normal s/he appears.

3. never try to have a conversation with a 400#+ h*ll's angel pt. alone. i am 5'4" and weighed

about 110#, and was absolutely no match at all. he grabbed me and suddenly i was airborne.

he yelled "make a wish, b*tch! he had grabbed me by my right shoulder and left hip. fortunately

three large male aides heard him, then heard me scream.

I also work on an acute care locked psych unit and recently made a mistake when I should have known better. I had 2 male patients get into a physical altercation. One was psychotic and paranoid but worked well with me; the other had anger management issues but was actually in the process of being discharged.

Without thinking I jumped in to break it up. (At 5'3 and 100 lbs, what in the world made me think I could stop 2 angry men?) Got caught in the middle and a punch intended for the other guy hit me in the face instead.

Their doc was on the unit and got there in time to see me thrown to the floor. He quickly diffused the situation. Expedited the discharge of the one who hit me, and increased the medication of the other.

Lesson learned: Don't get parental and think because patients know and respect you they'll listen when you jump in and yell "stop"!

Like others I'm not saying but I do learn from them.

A more harmless....humorous one.....I was walking with my new patient, holding her chart, bringing her back to her room. I was looking at her "face sheet" which has the patient's name, address, phone, and insurance coding information, to remind myself what she was having surgery for.

She was getting a breast biopsy for fibrocystic breast disease. The clerk had mistakenly entered cystic fibrosis...I blurted out..."You have cystic fibrosis!" She gasped....."I do!" I immediately realized the, my, mistake and explained the mix up, ha ha...it took a few minutes to convince her. I'm sure for a few seconds she thought maybe she had it, her doctor just hadn't told her yet? (I also had the clerk change the coding.)

I gave a patient a calcium pill ( huge horse pill) to swallow whole. He immediately started to gag. I took the pill outbid his mouth and gave him his water. I noticed then that he was on thickend liquids and I should have crushed the pills. I thank God for the rest of the shift that he didn't die over this. I still think about it to this very day.

I once gave insulin sub q instead of ivp. I was rushing and didn't thoroughly check the 5 r's .

One time I pushed reglan too fast.... And we all know what that does.....

mmm.... Someone gave me Reglan IVP too fast once.... that was terrible.

I'm just finishing my preceptor, the other day I was on an out pt/urgent care department returned from my break and the nurse I was working with pointed to the morphine and gravol she had already pulled out and said pt X needed it. I confirmed the order, did the calculations correct, got it double checked by the nurse (Im paranoid about giving the wrong amount so I always do the math), confirmed the patients ID, and even confirmed that they could have morphine, another nurse observed me give the IM. Then I saw the allergy bracelet under their sweater, there was allergic to codeine. I seriously thought I was going to vomit, I immediately got a hx on their reaction (swelling), and told the supervising RN, who said we would observe the pt, and explained that doctors frequently prescribe morphine to patents with codeine allergies. I checked on the pt multiple times, did VS, and thankfully they had no reaction, even called the hospital 3 hours after I got home to confirm the pt was okay. I feel like a failure and I keep analyzing what I did and seeing all the possible times I could have prevented this mistake. I'm super ashamed. Called my supervisor from the university crying. She was a great support, told me I handled it correctly and that I'm accountable. I keep trying to think that everyone makes mistakes, and that we should not be judged based on the mistakes we make but on how we handle those mistakes... but I cant help but think maybe I should have considered another career choice...

I am a new nurse. I've only been at my hospital for 8 months. This is great reading these. Your experiences just may protect me from repeating them. Thanks for sharing! Mine are both fall situations.

The first one was when I was still in clinicals. One of my fellow students asked me to cover for her while she took a break. I just said sure and got a short report but neglected to find out their assist status... ummm, probably one of the most important things to know. I answered one Pt's call light (a hip replacement) who asked if he could get up to go to the bathroom, "SURE!" I say with an enthusiastic smile. He gets there fine and is standing there with a walker blocking his way to the toilet and says, "maybe you should just hand me that urinal" I stepped away from his side two measly steps to grab his urinal, he went down, and he went down hard. Come to find out his block was just recently removed and he had not stood up yet. I should have had two people there with hands on him at all times. He thankfully had no injuries. I was expecting a dislocation and return to surgery.

You would think I would learn... nope. Just last week I had admitted a woman who was ambulating independently with no signs of weakness. She was on the toilet and said she felt dizzy. What I should have done, called someone to come in and help get her down to the floor. I should have been Pt focused. Instead I was data focused and felt I should get her blood pressure. I suppose that wouldn't have been to terrible if I had someone there to keep a hand on her while I did but no. I grabbed the blood pressure machine and took her blood pressure. As I was writing my data on a paper towel she went down, face first, onto the floor. I thought for sure she had broken her nose or something but she never developed even the tiniest of bruises. :facepalm: God was with me on that one.

levophed bolus...nuff said

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