Your worst mistake - page 14

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   appleorchard
    Two things kind of funny from my first GN job in the mid 80s, one not so funny in L&D 10 years later. I was working on a 20 bed oncology floor that also served as an overflow floor as well as the VIP unit(strange bedfellows indeed). We had an addict recovering from an abcess scheduled to leave that morning. Wanted to take a few things out to her car so she wouldn't have so much to carry when she left. I went to ask the other nurse--I still can't believe I was this stupid in 1986--and when I got back, the patient, of course, was gone. Did she come back? Nope!

    Another night there were 2 of us GNs on with 1 other nurse. The other GN discovered a tick on one of our old guys thigh--who knows how it got there? She was working really hard on getting it off when I came in and our conversations went something like this:
    Me:"Abby?"
    Abby:"Hold on, hold on, I think I've got it!"
    Me: "Abby, I think he's dead."

    Yes, the man who fortunately was a DNR had expired during his tick removal and Abby was so focused on the tick that she didn't noticed he was no longer breathing.

    The third was on L/D; the OB ordered an IV pain reliever, I forget which, and after I gave it the patient's contractions stopped almost immediately. I was SURE I'd given her Brethine by mistake and even took all the vials out of the trash, looking to see. Called the doctor, who said not to worry, just wait and see what happens. She started contracting again within an hour and I've never been sure that I didn't push Brethine.
  2. by   apaisRN
    Aneroo, how could you? Give two OTC meds that could hurt very few people without an instructor? Your instructor sounds like a control freak. I don't think any of mine would have gotten so upset about it. If I'd pushed morphine alone, maybe, but not tums.

    As far as unreported mistakes . . . well, I've had a few too. When you don't have enough time to care for your patients you hate to take extra to do piles of paperwork. If it's in any way harmful to the patient, of course you report it, but if you gave an antibiotic at 6 instead of 4 because you were crazy busy and lost track, you let it go. It's just triage. Real nursing is different from theoretical nursing.
  3. by   UM Review RN
    In the USA is it common practice for RN's to doublecheck injectable medications and sign for them or does it not occur?
    I know that years ago, we had certain meds that had to be double-checked, such as IV Digoxin, Heparin, Insulin, and IV narcotics--can't recall the whole list, but the list hung in the Med Room.

    Nowadays, we don't have to check any of them. I personally feel safer getting a check on my cardiac boluses such as Cardizem, heparin, and other cardiac gtts like Dobutamine.

    I recently surprised a couple of nurses by asking them to double-check a calculated dose. For instance, if I have to give 0.5 mg of Haldol IV and it comes in a 2 mg/ml vial, I'll have someone double check to make sure I didn't screw up on my math and give the wrong dose.

    Although once, I saw two nurses agree on the wrong dosage :uhoh21: ....caught that one before it got to the patient and we all agreed it was an easy mistake to make, so we reported it to Pharmacy and Risk Management as a near-miss.
  4. by   Sweetness
    As a student in clinicals, my friend and I ended up putting hemmroid cream on dentures, unbeknownst to ourselves.
  5. by   DutchgirlRN
    I work Med/Surg but yesterday got pulled to CCU. I got a new admit (87 y/o)whose dx was: CHF exacerbation, and bilateral pleural effusions. Really nice man, a walkie/talkie. He had a NGT gtt when he came from the ER at 5cc/hr + NS @ KVO, then the cardiologist came in and added lasix/diurel drip at 10 mg/hr and dobutamine and dopamine at 2mcg per kilo gram which was 10/cc an hour each. The label on the lasix said 10 mg/hr (25cc) which I took to mean 25cc and hour but it was actually 10 cc an hour. He put out 5,000 cc urine in 8 hours. He felt better needless to say. His legs were cramping. I got a stat K and it was 3.5 and I turned the lasix off to talk to the charge nurse. It was then that we realized that it should have been running at 10 cc/hr. Oh I felt soooooo bad. They assured me that my mistake would not in any way hurt the patient, they explained it to me and I completely understand what they are saying but I am so upset about making the mistake in the first place because I am so conscioncess. That's the only fear I have in my job is making med errors. I filled out an SOE because I want to accept full responsibility. I just can't get over feeling so bad about making a mistake that resulted in an overdose. I did learn a lesson. I should of set it at 10 cc an hour and then asked whether the 10 cc/hr or the 25 cc/hr was correctl
  6. by   GLORIAmunchkin72
    It's probably not going to be my worst mistake but I gave "breakthrough pain" oxy instead of routine oxy. There was only one pill left of the routine oxy that I was supposed to give until pharmacy came and someone put it in a little envelope in the narc's box. I, of course, failed to see it. The next day routine oxycodone arrived from the pharmacy and it was erroneously labeled "For breakthrough pain only". It just proves mistakes are made all around. You feel bad but you have to go on and try harder.
    Quote from DutchgirlRN
    I work Med/Surg but yesterday got pulled to CCU. I got a new admit (87 y/o)whose dx was: CHF exacerbation, and bilateral pleural effusions. Really nice man, a walkie/talkie. He had a NGT gtt when he came from the ER at 5cc/hr + NS @ KVO, then the cardiologist came in and added lasix/diurel drip at 10 mg/hr and dobutamine and dopamine at 2mcg per kilo gram which was 10/cc an hour each. The label on the lasix said 10 mg/hr (25cc) which I took to mean 25cc and hour but it was actually 10 cc an hour. He put out 5,000 cc urine in 8 hours. He felt better needless to say. His legs were cramping. I got a stat K and it was 3.5 and I turned the lasix off to talk to the charge nurse. It was then that we realized that it should have been running at 10 cc/hr. Oh I felt soooooo bad. They assured me that my mistake would not in any way hurt the patient, they explained it to me and I completely understand what they are saying but I am so upset about making the mistake in the first place because I am so conscioncess. That's the only fear I have in my job is making med errors. I filled out an SOE because I want to accept full responsibility. I just can't get over feeling so bad about making a mistake that resulted in an overdose. I did learn a lesson. I should of set it at 10 cc an hour and then asked whether the 10 cc/hr or the 25 cc/hr was correctl
  7. by   nesher
    I have several mistakes that I always tell the new grads I precept - it takes me off the pedestal and makes me seem human.
    The first was when I was several months into a new job/state. It was nights of course I was in charge - I with several months experience total. At the end of report at 11:30 I was called into a patients room. She was in the bathroom, which looked like a blood bomb had gone off. Blood everywhere. I don't know how she did that - the blood was on all 4 walls - waist high. She was covered - the bedroom and bed looked a massacre had taken place. She had had a vag bleed - cervical Ca. At any rate, stat hct, etc etc, endless cleanup, I was to say the least a tad frazzled when I finally had her settled. My next patient called for me and asked for benadryl. She was a sickle cell patient - frequent flyer and the narcs made her itchy. I grabbed the med and gave it to her. This before the days of PYXIS and all the meds were jumbled together in a bin - all their prns etc. As I walking out the door to get something else for her, she sat straight up and started to seize as well as projectile vomit - all the way across the room.
    What had I given her? I can tell you there is a difficult to breath feeling as well as that gnawing knowledge that I must have given her something bad. I actually went back into the med room and dug through the garbage - I was sure I hadn't!
    Clearly I had. It turned out I had given her compazine instead of benadryl - the containers were the same size and the print on each of them was in black - thus my mistake - I had in my frenzied state from the other patient and her bleed out had not looked closely. Now granted it should not have been in her bin since she had an allergy to it, but it doesn't excuse my not checking closely. She ended up being fine - the hospital paid for her admission and I was forevermore uncomfortable around her. This wasn't my last med error that year though.
    The second biggie I did was with a 19 year old with neurofibromatosis (spelling) which had become cancerous - She had a huge inoperable abd tumor that made her look preg. This tumor had also wrapped around her ureters and among many problems she had was enormous pain. She had a forest of IV pumps in her room on both sides of the bed. Several pumps were hooked to the caths keeping her ureters and infused medication - I don't recall the purpose) - she also had antibiotics, IVF, 2 PCA's one with MS one with versed and another pump for her epidural gtt. This was before the days of locked epidural specific pumps. She had come racing back from a procedure and the bag was empty - so I changed it quickly and got her back into bed - an arduous process. Her pain kept increasing all evening.
    It wasn't until the next day when I go to work that I was told what I had done...I had hung Vanco instead of whatever it was she had for her epidural - talk about your heart sinking to the floor. It turns out a person can get Vanco into the epidural space, and because the gtt was at a slow rate she didn't exceed the amount allowed. I was her primary nurse so I continued to care for her until her death. I felt pretty bad about contributing to her pain though...
    Those two mistakes occurred when I was a newbie and I recognize their value in teaching me to slow down - take the time to look at what you are giving and to remember you are a human and to be thankful when your screwups don't permanently harm someone.
  8. by   *PICURN*
    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 guys don't have to double check insulins w/another RN? I know in nursing school we were told that even as RN's we have to double check insulins w/another RN....I think heparin as well?
    You should be proud of yourself for coming back and admitting the mistake!!!!!!!!!
  9. by   letina
    Quote from Sweetness
    As a student in clinicals, my friend and I ended up putting hemmroid cream on dentures, unbeknownst to ourselves.
    :roll :roll :roll
    funny!
  10. by   DutchgirlRN
    In the US we have to have insulin that we pull up double checked by other RN and then signed off. We do the same with IV heparin, IV digoxin, and IV lopressor.
  11. by   NurseFirst
    Quote from DutchgirlRN
    In the US we have to have insulin that we pull up double checked by other RN and then signed off. We do the same with IV heparin, IV digoxin, and IV lopressor.
    We were taught "Did I Kill Him" to remember the names of the medications which have the greatest potential for harm if given incorrectly:

    D : digoxin
    I : insulin
    K : postassium
    H : heparin

    NurseFirst
  12. by   MrsStraty
    Quote from NurseFirst
    We were taught "Did I Kill Him" to remember the names of the medications which have the greatest potential for harm if given incorrectly:

    D : digoxin
    I : insulin
    K : postassium
    H : heparin

    NurseFirst

    I like that one.....Did I kill Him.
    Here in Dutchess County, NY we do NOT have to check insulin with another nurse. I graduate in May 2005 and I have given insulin plenty of time and never heard of that rule. Also I work at a hospital where I have never seen the nurses double checking insulin.

    MrsStraty
    ADN grad in 11 weeks!:hatparty:
  13. by   busylynn
    I too follow those same rules when passing meds. It has saved my behind more than once. A lot of my coworkers think that I am a little anal (teehee) but I would rather be anal than make a life threatening mistake! Keep up the good work!
    Quote from RainbowSkye
    Oh, my gosh, where to begin? I'm very lucky that I almost made a terrible med error my first year of nursing - I drew up epi instead of inderal to give iv push to a patient in svt (this was way back in 1974)...would have killed the person if I hadn't realized what I had done before I gave it. This taught me very clearly that even I can make a mistake (I'm kidding here guys) and I am very careful when giving meds.

    One thing has helped me. I have a few rules that I never deviate from:
    1. I never give medication that someone else has drawn up (even if I see them draw it up - they can give it). Same thing goes for po meds unless they're still in their little labeled pack.
    2. I never have more than one syringe in my hand unless they are both labeled. Yeah, I think I can remember that the phenergan is in this one and the saline is in that one, but then the phone rings or another patient vomits and I lose my train of thought...
    3. When I get that funny gut feeling, I double check and then double check again. There are some things which should sound the alarm (like that patient saying "that looks like a lot of medicine in that syringe") or when it takes 20 vials of something to get the proper amount of medicine.
    4. I always ask allergies before I give the patient the medicine cup or give an injection. I can't tell y'all how many times a patient tells me they have no allergies when I triage them then right before I give them the shot, they say, "no, no allergies other than penicillin".
    5. This is a gut feeling one too. If the doc says to give something I'm unsure or uncomfortable about, I double check, make sure it's in writing and double check again. I won't give anything that I know is wrong - like inderal 80mg iv - the resident swore up and down it would be okay. Then wouldn't give it himself when I refused to give it.
    6. I save med containers. I look at the label before I break it open, as I draw it up, after I draw it up and then after I give it. Compulsive I know, but better to know you screwed up as soon as possible.
    These rules have helped me avoid many med errors, but not all. I have noticed that most medicine errors are communication errors though. I thought the doc said talwin, he swears he said tylenol #3. It helps if you can have everything in writing first. Since I work in the ER it's not always possible.

    My worst error wasn't a medication error. I took care of a 17 yo boy who died in the ER during a terrible asthma attack. The doctor was in a room with all of the family telling him what had happened. Two family members came down the hall from that direction asking me if they could see "Paul". I said of course, and went with them to the room. As I took them in, one of them said, "Oh, my god, is he..." and I interrupted and hussled them out of the room and back to where the rest of the family had gathered. I really thought they knew about the death and wanted to see his body. I felt awful, but these people were actually very understanding.

    It's a difficult job we've all chosen.

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