Your worst mistake - page 16

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   FNimuaeMae
    I've only been working ICU since last July. Had a patient being discharged to another facility, and was trying to get all the paperwork in order as he had been with us for almost 3 months and it was a complicated case. Trached, occasionally on a vent, flow-by trials. He called me in, was trying to communicate while on his trial so I put his passey muir talking valve on, left it on and hurried along on my busy way. A while later I am working on the paperwork, looking at the monitors, and his HR was in the 30's and 40's where it HAD been in the 80's. I go check him out....unresponsive to shaking...call the MD in while the team is still on rounds. We get the atropine out...RT comes in and says "WHO PUT THE VALVE ON!!??!?!?".

    My fault. Learned something new....didn't know you had to deflate the trach cuff with the talking valves, as usually when I had seen him wearing it, someone else had put it on correctly. Will NEVER do that again.

    And talk about being hysterically upset afterwards... the other day was NOT a good day.

    But everyone was very kind, understanding and supportive. I have such great coworkers... and supervisors.
  2. by   FNimuaeMae
    The patient was fine afterwards and still got transferred that morning.
  3. by   hollyster
    The error that haunts me happened while I was in nsg school. I was working fire/rescue an decided to become a RN.
    On my way home a young woman ran out into the street. The car in front of me hit her. I grabbed my medic bag and went to assess the pt. The pt had a head wound and an open fracture of her right tibia and was bleeding profusely. I gloved up before touching her. As I was gloving, a woman arrived on the scene and stated that she was a nurse. She started to apply pressure to the leg wound. I told her to get some gloves out of my bag but she just looked at me and said "this is a child." By the time the ambulance arrived the I managed to get a c-collar on her and fully assess her. I gave report to the medic and they transported the girl.
    The next day I went in for pediatric clinicals and by chance the young woman was assigned to me. While getting report I was told that the pt was MVA and HIV+. When I walked into the room I realized who she was. I felt sick. All that I could think of was the nurse that had been holding her leg wound. I did not get her name or know anything about her.
    But it reinforced my assume everyone has something contagious attitude.
  4. by   Labrys
    Quote from reyna
    my biggest mistake was...going to nursing school just kidding
    Honestly, I gotta say after reading some of this, I'm really starting to reconsider my choice...I am planning on going to nursing school next fall. More and more I am thinking radiology is a better idea. :uhoh21:
  5. by   skemergirl
    My worst "med error" was when I first started in the Pediartic ICU. We were really busy and I had 2 pts on q3h bolus feeds of MBM (maternal breast milk). This needs to be double checked with 2 RN's (or a care partner or a parent). This should be done at the bedside but because we were busy I caught someone in the hall & said this is for so & so in room 9. Well, I proceeded into room 6 and hung the MBM. Yep, wrong patient and YUCK!!. We had to have the mom for room 9 and the patient in room 6 do HIV tests! Breast milk is treated as a narcotic for the double checks because it is a body fluid. I ALWAYS have the co-checker come to the bedside and check the name band since then.
  6. by   MrsWampthang
    .....................................
    Last edit by MrsWampthang on May 27, '05
  7. by   PicklesRN
    Quote from moia
    I did see a doctor kill someone once , it was really awful because I had begged that doc not to give that drug because a week before he had nearly died from it. ...
    I was working ICU one night and the resident ordered Augmentin for a patient. It came up in liquid form and the resident was going to give it IV! Yes, IV! I heard the nurse all but yelling not to give it and he was the type with the attitude he was the doc, the nurse was but a lowly 'gofer' ... you know, go for this and go for that.

    She kept begging him not to give it, she said it was PO only. He insisted it wasn't, it was IV. Finally the nurse ran out to get the clinical RPh and they ran back to the room just as the resident had finished giving Augmentin IV. The RPh asked what the h*ll he was doing?

    The RPh went on to ask when he has ever known Augmentin to be made for IV use and the nurse chimed in to add ... and since when do IV drugs come in Bubble Gum flavor!

    Finally, the resident caught on and realized what he had done. Amazingly, the patient was fine and suffered no problems becuase of it.

    I fully understand human error will happen. We are all human and we will ALL make mistakes. But it is nothing but stupidity and ego when someone is begging and demanding you stop and think about what you are doing and you ignore the huge issue the nurse was making out of this. When someone is that adamant there is a problem, you don't just ignore her, you stop and think.
  8. by   PicklesRN
    Quote from barefootlady
    I am sure if I rack my brain I can come up with a mistake I have made recently, but my biggest mistakes have been not being assertative enough when I KNEW there was something wrong with the patient and no one would listen.
    I have one of those. It was about 15 years ago and to this day I feel horrible about it and it still haunts me. I knew my patient was not doing well on her meds, I knew she was pretty darn stable and doing well and suddenly some bright doc decided she needed mega treatment for mild asthma. She was Paranoid Schiz so she was already on a slew of psych meds and the doc ordered a huge amount of meds for mild asthma.

    If you looked at her MAR you can't really say the drugs were not okay to be given together but how many studies have been done with those specific 21 different drugs? Polypharmacy at its best.

    Within 24 hours something was very wrong. I called the doc and he said she was fine. I told him she wasn't, he reminded me he was the doc. The next morning she was dead. Just as I came into work she was coding. Her face was the size of a small watermelon. I *knew* something was wrong but I didn't push hard enough. Her symptoms were not really specific the previous day, it was one of those things that I knew her well enough to know something was very wrong. Vitals were fine, she had no complaints... but she was having a reaction to one or more of the new drugs.

    I still think of her often. I regret that I didn't push until someone listened to me. I could have easily pushed the issue but I didn't.

    For me the lesson was to listen to that little voice in the back of my head, it rarely leads me in the wrong direction.
  9. by   Daytonite
    When I was a head nurse I had to deal with two different medication errors that I would like to share with you all.

    The first was done by a young RN who had been out of school almost a year. A doctor had written an order for Morphine Elixir xxmg prn pain. He did not write the route. He assumed the nurses would know that the Elixir would be given orally. This nurse did not. Nor did she question the order. Morphine Elixir is a beautiful bright blue color. I cannot think of any IV medication that is blue. However, this young nurse drew the amount needed into a syringe and injected it into the patient's IV. It was then that the nurse began to question her decision to inject this medication IV. The patient suffered no adverse effect, but we did some serious counseling with this nurse and had her complete a medication administration program with the education nurses and put her on probation.

    The second incident occurred with a graduate nurse. Her preceptor watched in horror as she drew up a dosage of a patient's insulin in a 3cc syringe with a 1 inch needle on it. The preceptor watched quietly. As the new nurse was capping the needle, her preceptor starting asking her if she felt that she had the correct dose and had prepared it correctly. Again, the preceptor was horrified when the nurses' response was positive and that she was ready the give the Insulin. At that point, the preceptor stopped her. Several other incidents just as horrifying occurred over the next few weeks and this lady was, unfortunately, terminated. We were informed that she had failed her state board exam which may have been a blessing for any future patients. I still wonder how she was ever able to pass her nursing courses.
  10. by   PicklesRN
    Quote from Daytonite
    He assumed the nurses would know that the Elixir would be given orally. This nurse did not. Nor did she question the order. Morphine Elixir is a beautiful bright blue color. I cannot think of any IV medication that is blue. However, this young nurse drew the amount needed into a syringe and injected it into the patient's IV. It was then that the nurse began to question her decision to inject this medication IV. The patient suffered no adverse effect, but we did some serious counseling with this nurse and had her complete a medication administration program with the education nurses and put her on probation.
    I had decided not to write of a similar story because I didn't think it would be believable but after your Morphine story I have to tell this one. I certainly didn't believe it when I was told, I had to see the paperwork for myself.

    An older hospital RN had an order for 100mcg of Levothyroxine IV qd. Pharmacy printed the sig on the label correctly however the person filling the baggie put a 100mcg Levoxyl tablet in the baggie. For whatever reason this error was not caught in the pharmacy and the drug was sent to the floor.

    The nurse took the tablet, crushed it, mixed it with NaCl, heated it, drew it up in a syringe and injected it IV. She thought it was okay because she used a filter needle.

    The nurse should have probably retired a long time previous to this incident but she didn't. So the hospital gave her a choice, either retire voluntarily or be terminated. She retired. I suspect she probably lost her license but I don't know that for sure.

    I don't understand errors such as this or the one you posted about the Morphine. I can see errors where you give the incorrect dose or incorrect drug, but how could someone crush a tablet, a common tablet and think this is okay? Or how could someone draw up a dose in a syringe from a non sterile bottle? Seriously, what would you do... pour a bit into the cap of the amber bottle and draw it up? Isn't that about the same thinking as drawing up the drug from a suppository? How can a nurse not know better?

    An RPh I know thought that if you used a small enough micron filter that it would filter out all of the bacteria. How can someone get through 4-8 years of college and not realize this? The RPh defended the nurse with the Levothyroxine tablet because if she used the correct filter she thought it would be sterile.

    The morphine, the tablet given IV... that isn't human error, that is something much different, I just don't understand how anyone could make that kind of error. Again, wrong dose, wrong drug, wrong frequency... I understand. But the others I just don't get it.

    The spooky part of any med error for me are those that might have happened and I never realized it. You know, the big 'what if' questions. Most med errors can typically be reversed but only if we are aware we did it. Something I started doing a long time ago was after my checks and rechecks when I give a med I usually tell the patient what each drug is and what it is for as I am giving it. Something about saying it outloud makes a difference and often times the patient knows what they are supposed to be getting so that is yet another check.
  11. by   Daytonite
    An older hospital RN had an order for 100mcg of Levothyroxine IV qd. Pharmacy printed the sig on the label correctly however the person filling the baggie put a 100mcg Levoxyl tablet in the baggie. For whatever reason this error was not caught in the pharmacy and the drug was sent to the floor. The nurse took the tablet, crushed it, mixed it with NaCl, heated it, drew it up in a syringe and injected it IV. She thought it was okay because she used a filter needle.

    The nurse should have probably retired a long time previous to this incident but she didn't. So the hospital gave her a choice, either retire voluntarily or be terminated. She retired. I suspect she probably lost her license but I don't know that for sure.

    I don't understand errors such as this or the one you posted about the Morphine. I can see errors where you give the incorrect dose or incorrect drug, but how could someone crush a tablet, a common tablet and think this is okay? Or how could someone draw up a dose in a syringe from a non sterile bottle? Seriously, what would you do... pour a bit into the cap of the amber bottle and draw it up? Isn't that about the same thinking as drawing up the drug from a suppository? How can a nurse not know better?



    I'm with you on this. I was flabergasted when I heard about the Morphine incident. My own first thought had been "didn't she realize that it was blue liquid she was shooting into the IV line?" With the Insulin thing I was impressed that the mentor was able to just stand by and watch this poor girl drawing up Insulin in an IM syringe. She later told me that she was more fascinated with the idea of trying to figure out what might be going on in her mind. As I recall there were many other incidents with this graduate nurse, but this one stands out in my memory. I do remember that who ever worked with her watched her like a hawk because they were all afraid she was going to hurt someone.

    This also reminds me that it is not as easy to terminate someone as you would think. At least at that hospital we had to have the written documentation to back up incidences like this. And even then, it was reviewed by the Personnel officer and the final decision to terminate any nursing personnel was ultimately made by the Director of Nursing with the Personnel Director. So, for those out there who wonder what administration is waiting for to fire people like this, you have to know that they need clearly written accounts of these incidents when they occur. Unless the mistake is a real doozie, these written up incidents eventually add up in a persons file. And, I don't care what they tell you, nothing like those kind of incidents, ever--ever--gets thrown away. They are kept in order to establish a pattern that leads the genius in question OTD (Out The Door).
  12. by   Mulan
    Back in the olden days, when they had glass syringes, they also had tablets of injectable morphine which were crushed and mixed with diluent and then given IM.
  13. by   RainbowSkye
    Quote from Mulan
    Back in the olden days, when they had glass syringes, they also had tablets of injectable morphine which were crushed and mixed with diluent and then given IM.
    Back in those olden days when I started my nursing career (diploma grad 1974) there were several medications we mixed with a sterile dilutent and gave IV. I don't even recall using a special filter.

    Interesting that they fired the RN who gave the levothyroxine and that she maybe lost her license. I wonder what happened to the pharmacist who sent down the med?

    In this case I don't actually consider this a medication error, but a communication error.

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