Your Worst Mistake - page 15
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
Feb 21, '05Quote from MrsStratyI always like that extra check. One time, however, both I and the RN I was working with read the glucose meter upside down (I had double-checked because it was lower than his usual readings)--we read 112 and it was 211. I discovered it because this particular glucometer had to be returned to its station where it would input the glucose read, time, etc. into a computer, and I had to turn it around. We've worked in other hospitals with glucometers which did not have a cradle where it was to be returned.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.
ADN grad in 11 weeks!:hatparty:
Feb 21, '05We were taught to double check insulins...but who do you check with when you are the only nurse in the building?
Has anyone had a serious error from the Pharmacy and not noticed?
Feb 21, '05Quote from DutchgirlRNat my hospital too - also, when initiating PCA's.......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 also found that having pre-printed/fill in the blank/check the box orders for insulin, it has helped on our insulin med errors - it is no longer the number 1 med error med
Feb 21, '05These posts about med errors are seriously freaking me out. I have only read one page (most recent posts) and I am horrified. I know med errors occur quite frequently in fact as a patient I had a nurse give me 150mg IV demerol when it was written as 150mg IM. WOW that was really interesting. I do have a high tolerance for pain meds but that was a little too much. They never had to give me narcan or anything (thank god) but I will say my pain was cured for about 6 hours.
But honestly, this is making me think. I am in my senior year of nursing and I think these stories should be told at school! I think it would also freak some people out to be extra extra careful.
I cannot think how bad it would be to actually harm or kill someone cause you read a label wrong or didn't check the order with another RN. I just can image the gut wrenching feeling, kinda like when you do something wrong (like getting pulled over for speeding, or something like that) but it would be ten times worse!! :uhoh21:
Wow, thanks for these stories and I am sorry a lot of you had to learn the hard way about re-checking. I think it is so much better to be anal about medications. I know I will! Curleysue :stone
Feb 21, '05My worst mistake happened just about 2 months ago....a colleague's pt became unresponsive. After a short period of time, it was determined that the pt's glucose was 25. While her primary nurse went to call the doc.....I went to the Pyxis and grabbed an amp of dextrose. My colleague rec'd the TO and we pushed it. The pt did not immediately respond so we went to push another amp. By that time the doc was on the floor. He saw me drawing up the dextrose. Unfortunately, I pulled sodium bicarb instead of dextrose both times. I was horrified! The doc called for the crash cart and used the prefilled dextrose syringes. The pt's BP bottomed out, and her resp ceased. We coded her and brought her back. She was then transferred to ICU. I felt just horrible about the whole situation. I tried quitting the next day but the manager and director of the unit encouraged me to come in an talk to them. I did and am still working the unit. However, I went thru several days where I didn't work. I couldn't bring myself to work. I broke the cardinal rule of medication administration. I did not triple check the med. I didn't feel competent to work the floor. I didn't feel that my colleagues would be comfortable working w/ me. I didn't think that the doc would/could trust me/my nursing skill ever again.
Well, I have since gone back to working the floor. The memory of that whole night still haunts me. The pt eventually expired but not because of my error but because she was septic secondary to numerous decubiti. The pt's family sent the nurses who "saved" their mom the nite she became so sick a thank you card. I don't believe that I was deserving to be included but I was. I am still working my way thru this whole situation. I understand what ppl tell me...I am human and humans make mistakes. The best you can do is learn from your mistakes to become a better nurse and continue on w/ your practice. So that is what I am trying to do.
Feb 22, '05An instructor told us that a co-worker kept a pt's nitro paste on his bedside table and the visually impaired patient mistook it for toothpaste!!!!
Feb 22, '05I am still reading through all these posts and like I said before, its definetely teaching me A LOT about how crucial it is to recheck med orders and all the medication steps over and over. Wow. This is an excellent thread. Honestly.
Anyways, I wondered after reading some posts that I know mistakes happen to every nurse no matter how careful they are it seems like it will always happen some time. But I questioned, do you guys think that because nurses these days have more patients because of short staffed units that the stress and constant running behind, or just plain being overwhelmed, doesn't that contribute to a higher incidence of med errors?
That thought popped into my head after reading a couple pages. I know its not the number one excuse that med errors are made but I definetely question that it has a major inpact on incidence. Do you guys think so?
Feb 22, '05In nursing for 30 years, once set the heparin to run at 100cc/hr instead of 10, ran only 30 min, no harm done, but I got very pale....also some how I got 2" of nitropaste stuck on the back of my arm, didnt notice, but I dropped like a stone after wondering why I got such a sudden headache. What I feel the worst about was a few years ago we had a man come in DOA. Some other people came in with him, I was asking the ? about family and such, They just left the Ed. I waited about 2 hours got the mans old record found a wife listed as next of kin, called the number, a female amswered, I asked if the was,Ann, (I will never forget the name) I did the usual, he has been injured adn you need to come to the er as soon as possible, she starts getting very upset and screaming, is he dead,is he dead over and over. I had to say yes , I'm so sorry. She hangs up.So now i am about to call the police when I get another call, from one of the people who came in with him , screaming at me why did I tell her this over the phone? Well turns out I spoke to his 17 year old daughter,not his wife who unfortunatly died a few months ago. The people who came with him had gone to tell her in person, but didnt bother to tell me that was what they were doing.The home was also only 15 min from hosp,they didnt know how to tell her so they stopped somewher to discuss it.
It was just a giant mess of noncommunication, I still feel bad when I think about it. I just dont know why they didnt tell anyone theywere leaving and what they were doing.What pain that child had.
Feb 22, '05This one haunts me to this day. And will for the rest of my life. I was working agency at a home for MR children. Had a young lady, very active, with a trach. I worked nights, and in the am did care to get the children ready for the day. The regular routine for the regular staff was to put her back in her crib after am care so she could rest more, and/or keep her contained while doing care for others. There isn't enough staff to keep watch at 5am. Most of the time she would bounce in her crib until day staff got her out. So everyone would take the apnea monitor off, and the pulse ox probe off, and leave them off after am care, because the bouncing would make them continually alarm. No one told me the reason they took them off, they just told me that is what we do. Being agency I didn't want to buck the system, learned my lesson the hard way. Giving report to oncoming shift, CNA comes running, child is not breathing, pulled out her trach, run to check, she is in cardiac arrest. Trach reinsterted, 911 called, MD called. Epi down trach, CPR, O2, sent to hospital. Too much time without O2, severe brain damage, now needs a vent, and is a vegetable. It still breaks my heart. I learned to NEVER take off the apnea monitor from a trached child, especially when they are out of my line of sight.
Feb 22, '05Quote from AnnasmomRNtobeNo, sometimes veins just cannot handle it, esp with IBPB... the antibiotic could have been very irritating to the vein itself. You did the right thing. You kept check on your patient, and as long as you documented everything, you're fine. -AndreaIs 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.
Feb 22, '05My very first nursing job was in an allergist's office. A client had come in for a second round of tests, having previously having skin tests on the forearm. The second round of tests were done intradermally in the upper arms. There was nothing in the first set of tests that indicated any major allergies. The office assistant told me to hold off on doing the second tests because the Dr. wasn't in the office, but the nurse orienting me told me to go ahead and proceed because as long as the Dr. was in the building it was OK. I was a little less than halfway through testing when the patient started saying that she didn't feel right. She coudn't tell me anything specific. I did two more injections, then realized that she was probably starting to have a reaction. I stopped testing and called in the nurse that was orienting me, she said "Get out of here, I should've known something like this would happen!" The office assistant paged the Dr. I went and drew up the Benadryl and steroids. The patient was ok, thank god. But the nurse orienting me lied, denying that she told me to proceed with the testing. Needless to say, I quit that job shortly after all of this happened.
Feb 22, '05By far, my worst mistake was comming to OKLAHOMA to practice nursing, I've worked in 5 other states and never had any problems, with employers or coworkers, I come to OKLAHOMA and my license is suspended and I'm on the OIG Exclusion list for a Lortab addiction that had nothing to do with my profession, meaning no diversion. Good Luck. 's with wolves.
Mar 10, '05I've always heard that it's not the case of "if" you ever make a med error, it's the case of "when" you make it. And it's always that one time you didn't triple check because you were really busy, felt you were behind, etc. If any nurse out there tells you they've never made a med error, they're lying. Nobody's perfect. The first (and only so far...knock on wood) med error I made was grabbing a bottle of Vanco and hanging it on the wrong patient. The only difference between the two bottles was that one of the doses were just slightly higher than the other (one was 700 mg and the other was 750 mg or something like that). I got a weird feeling immediately after I left the room. I went back after it had been infusing for about three minutes to double check the bottle (as I should have done BEFORE I hung it...gosh) and hello: wrong name and dose on the bottle. I stopped immediately and sought help from my charge nurse. I was very lucky in that situation, and I realize that I could have hung a completely wrong drug, which could have results in something horrible. I know you'll still worry about making med errors regardless of what we all may tell you on the site and especially after me telling you scary stories, but try not to worry too much. I am pleased to hear that you have a fear of making a med error; it shows me that you take being a nurse seriously, and that you care. Having that caution in the back of your mind at all times, keeping your guard up like that is good trait for a nurse to have. Believe me, if you do your five rights, three times, every time, you will catch potential med errors.