Your worst mistake - page 11

Here's mine: I was working a night shift, which to this day I truly detest. When I got report, I found I had a patient in acute alcohol withdrawal (which in and of itself makes me furious,... Read More

  1. by   stevierae
    Quote from nh_nurse
    wow, this is so much like my biggest error. I did the exact same thing. Instead of pulling up 4 units, I drew up 40. Even when the pt said, "why is there so much in the needle?" it didn't click. Like you, it was much later in the day when out of the clear blue it hit me. I immediately called work, and they informed me that she had bottomed out, but was currently stable. I reported my error to the DON, but even with her reassurance, I lost a lot of confidence in myself.
    Not criticizing anybody, but aren't nurses taught in nursing school anymore to double check heparin and insulin with another RN while drawing it up? That's what I was taught, both as a hospital corpsman in the aNavy 30 years ago, and when I went to nursing school (i graduated in '81.) I still do it to this day--always, always, always--check my insulin and heparin with another RN, or a surgeon, or an anesthesiologist as I draw it up. We verify what the label says together, and what's drawn up in the syringe. The more I read, I am fearful that this simple technique is not being taught anymore.
  2. by   stevierae
    Quote from nursemjb
    And this is such a big deal because.... Did it hurt the patient in any way???? I can think of a lot worse things than this.
    EXACTLY. I think those nurses who talked about it for a week were just being jerks. I've seen patients come to surgery with the wooden board that is slid under them during resucitation from cardiac arrest (CPR, defib, the whole 9 yards of a code) still under them. Look and see when the code occurred--oh, 48 hours ago or more....no harm done, though....

    Don't let this incident with the X-ray cassette bother you, Melissa. Trust me, they just had nothing better to gossip about that week.
    Last edit by stevierae on Jul 4, '04
  3. by   Tweety
    Quote from stevierae
    Not criticizing anybody, but aren't nurses taught in nursing school anymore to double check heparin and insulin with another RN while drawing it up? That's what I was taught, both as a hospital corpsman in the aNavy 30 years ago, and when I went to nursing school (i graduated in '81.) I still do it to this day--always, always, always--check my insulin and heparin with another RN, or a surgeon, or an anesthesiologist as I draw it up. We verify what the label says together, and what's drawn up in the syringe. The more I read, I am fearful that this simple technique is not being taught anymore.
    To be honest with you, I wasn't taught that in school, and I'm not a new nurse. (Of course we checked and doubled checked all meds with our insturctor.) So for a while I wasn't checking insulin with anyone until I read it was policy after noticing a few people come to me to double check. They usually come with the needle and not the order, the accucheck or a copy of the med sheet. And no double-signing of the med sheets. But still this helps with big orders because if someone comes with 40 units of Regular a big red flag would come up.

    But surely you've been around long enough to know that what you're taught in nursing school and the real world isn't always true.
  4. by   stevierae
    Quote from 3rdShiftGuy
    But surely you've been around long enough to know that what you're taught in nursing school and the real world isn't always true.
    Of course--but Heparin and Insulin errors are the most preventable of errors, if only one would take the time to double check with another nurse. With Insulin, it isn't just dosage--it's TYPE of insulin.

    And with Heparin--well, there have been many preventable intracranial bleeds that occurred (and sometimes caused death) because somebody drew up and administered Heparin from what they THOUGHT was a multidose 1,000 Unit per cc vial--when, if they'd double checked the vial with someone, they would have realized that it was a 10,000 Unit per cc vial--or, even worse, a 30,000 Unit per cc vial. The vials are even COLOR CODED to prevent these errors--but, when people are in a rush and don't double check, they happen. I know, because as a legal nurse consultant I've reviewed cases like these, and I've also read about them in my own local newspaper. Such a preventable tragedy.

    They like to call this a "systems error" and blame it on the manufacturers, but, in reality, just reading the label and simple double checking, as we were taught to do in the '70s and '80s, (as were nurses before that era) could have prevented it. So, this is one thing that I still do, exactly as I was taught long ago. I think, though I cannot say for certain, that most RNs who trained in the '70s and '80s still do it this way. I know the OR nurses I work with do.
    Last edit by stevierae on Jul 4, '04
  5. by   Tweety
    The longer I'm a nurse the more paranoid I become. I'm not the cocky new grad I once was. The other day I had a vial of Digoxin that had .5 mg/cc. I went to a nurse and said "I'm to give .250 mg, which means 1/2 cc........am I right?". I'm that way with a lot of things no matter how simple the adminstration seems, Heparin and Insulin included.

    We had a rash of pharmacy errors a couple of years ago when we would order stroke Heparin protocols and they would prent up a medical heparin protocol and the nurses were following the wrong sliding scale for days. One can't always trust their med sheets either.

    It's an awesome responsibility.
  6. by   Farkinott
    Quote from AnnasmomRNtobe
    Is it always the nurse's fault when an IV infiltrates? I am a student, and just two weeks ago I was giving an antibiotic IV to a guy, my instructor was right there with me. I flushed it with saline first, which went in fine, so I started the IV and went to get the linen to change his bed with. I came back, and it had infiltrated. I shut the pump off immediately and called the IV team. About 15 cc had gone in. I didn't think this was my fault, but now after reading your posts, I am not sure.
    Don't beat yourself about the head about this one! It was just bad luck and as you are new you are hypersensitive to events of this kind.
  7. by   Farkinott
    Quote from nurse_robin
    Well, with everyone admitting their errors, here's my worst error:
    Fresh out of school in 1984, as a GN, working night shift with 15 pts (me and an aide), I had to flush all the saline locks. Back then we had boxes of hep lock flush, potassium, and benadryl on top of our med carts. Each box held about 24 sindgle doses of each med. I used to come in an draw up all my flushes to give during my first rounds..... Well I guess you can figure this out by now

    As the shift ended, I realized that I had a full box of hep lock flush and I had flushed everyone with Benadryl!
    :imbar

    Well, everyone got a good night sleep that night anyway! I still get goosebumps thinking about that!



    So glad that they have done away with that system.
    thankfully you didn't flush everyone with potassium!
  8. by   Farkinott
    after veiwing a lot of the post on this thread it makes me wonder why some of the drug errors happened. In Oz we always get an IV, IM or subcut drug checked by either an RN or drug endorsed EN. Many RN's choose to get oral drugs like prednisone or warfarin checked too (though there is no legal requirment). The checker then takes on a responsibility in that they are deemed to have given the drug too. The checker, of course, signs the medicaton sheet too.

    In the USA is it common practice for RN's to doublecheck injectable medications and sign for them or does it not occur?
  9. by   Ruby Vee
    Worst mistake I ever made was hanging heparin instead of Lidocaine. The patient was on both meds, and the bags were all near their 24 hour expiration. When I respiked the bags, I hung heparin on the lidocaine tubing and vice versa. Then the ectopy increased (duh!) so we turned up the "lidocaine." Then turned it up some more. Then went to another drug. I never caught my own mistake -- when I came back in the next morning, the night nurse told me he had caught it when the patient started peeing red. Uh-oh. I always follow my tubings from the patient to the pump to the bag now. Every time I hang a bag, every time I assess a patient.
  10. by   NurseCard
    Quote from nurse1975_25
    My error has kept me from working since the day it happened. I so terrified that I may make another mistake which may lead to a patients crash or even death. It was a busy day and I was overwhelmed (still no excuse) and my patient was on a sliding scale insulin. I took the blood sugar and she required FIVE (5) UNITS of insulin. to this day I do not know what was going through my mind but I pulled back to FIFTY (50) UNITS instead of the minimal FIVE (5) she needed. I did my checks that it was the proper insulin. I took the patients medication profile to her bedside and compared her armband to the profile and I stated to her that I was there to administer her insulin.

    Still not knowing that I had done the error I left the hospital at the end of my shift which was about 45 minutes later. I had helped her with her tray and asked her if there was anything I could do for her before I went off shift. (because sometime report & shift change take a while), she replied no.

    I was at dinner with my husband at a resturant and while eating my soup, which was the first part of my meal, IT HIT ME WHAT I HAD DONE! My husband saw my face and asked me what was wrong I immediately grabbed the cell phone and tole my husband to just leave money and drive me to back to the hospital. I called the unit and told them about the error - they said 50!?!?!?!?! I said yes I will be there in 5 minutes. They changed her iv fluid to 50% dextrose and ran it at 100/hr. I stayed with her doing continuous bld sugar tests until midnight. Her BLOOD SUGAR never dropped below 8.1 - in Canada (Ontario) normal blood sugar levels are between 3 and 7.

    I was praised and praised for coming back and admitting my mistake. I haven't worked as an RN since.
    You poor thing! *HUG* I am so sorry that happened to you!!

    I had a HUGE, long reply to this thread but somehow i lost it!!
    I am REALLY bummed out about that! It took me forever to type it.

    Oh well. Anyway, I screwed up royally just this morning, but what happened to me is actually minor compared to some of the horror stories I'm reading in here! I guess I should count my blessings. =)
  11. by   MadelineGlass
    Have you not worked since this incident by choice or did you lose license? I made the same mistake but caught myself after injecting 10....but i was about to push in 50 units. The doc brought it to my attention that he is not concerned with insulin errors....they can be fixed. I thought ......."oh yeah". so the fear of killing someone left wtih that when it comes to insulin. (i also have changed my way of doing insulin. So i did learn from the mistake)
    But i see today that my errors are largly part of administration and understaffing.
  12. by   mother/babyRN
    I was a diabetic teaching nurse but misread an insulin dose that was six units but written so it looked like sixty units..From that time on,even when I was certain of the dose, I always second checked with the doc...Pt was fine but I was a wreck for weeks afterwards. Certainly learned my lesson, however....
  13. by   mollyz
    Quote from nurse1975_25
    My error has kept me from working since the day it happened. I so terrified that I may make another mistake which may lead to a patients crash or even death. It was a busy day and I was overwhelmed (still no excuse) and my patient was on a sliding scale insulin. I took the blood sugar and she required FIVE (5) UNITS of insulin. to this day I do not know what was going through my mind but I pulled back to FIFTY (50) UNITS instead of the minimal FIVE (5) she needed. I did my checks that it was the proper insulin. I took the patients medication profile to her bedside and compared her armband to the profile and I stated to her that I was there to administer her insulin.

    Still not knowing that I had done the error I left the hospital at the end of my shift which was about 45 minutes later. I had helped her with her tray and asked her if there was anything I could do for her before I went off shift. (because sometime report & shift change take a while), she replied no.

    I was at dinner with my husband at a resturant and while eating my soup, which was the first part of my meal, IT HIT ME WHAT I HAD DONE! My husband saw my face and asked me what was wrong I immediately grabbed the cell phone and tole my husband to just leave money and drive me to back to the hospital. I called the unit and told them about the error - they said 50!?!?!?!?! I said yes I will be there in 5 minutes. They changed her iv fluid to 50% dextrose and ran it at 100/hr. I stayed with her doing continuous bld sugar tests until midnight. Her BLOOD SUGAR never dropped below 8.1 - in Canada (Ontario) normal blood sugar levels are between 3 and 7.

    I was praised and praised for coming back and admitting my mistake. I haven't worked as an RN since.
    Why not? You have lost all confidence? Since your mistake had a pretty good outcome, I would think you would be able to move on, if nursing is your passion. Don't be so hard on yourself!

close