Your worst mistake - page 17

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   PicklesRN
    Quote from RainbowSkye
    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.
    I don't know what happened to the RPh. She is gone but I don't know if that was on her own or if she was fired. Due to the huge number of mistakes I can only assume she was fired but I am speculating.

    As for a med error vs. a communication error... I can't see how it was anything but a med error. The label on the baggie was quite clear it was a 'vial' of Levothyroxine. Inside was a tablet. That was a med error on the part of the pharmacy since it was filled incorrectly. The fact that a nurse with a great deal of experience took an unsterile tablet, crushed it up, heated it, drew it up in a syringe and injected it knowing the drug comes in a vial...that was sheer stupidity. In no way is that a communication error IMNSHO.

    We have come a long way in administering meds since the 40's when this was likely common practice. We have also come a long way since the 70's as well.

    While this was certainly a mistake on both departments of the hospital, I can't see how anyone could consider such stupidity a communication error.

    Out of curiosity, what oral tablets did you give in the 70's by crushing, heating, and drawing up to give IV without a filter?
  2. by   RainbowSkye
    Quote from PicklesRN
    We have come a long way in administering meds since the 40's when this was likely common practice. We have also come a long way since the 70's as well.

    While this was certainly a mistake on both departments of the hospital, I can't see how anyone could consider such stupidity a communication error.

    Out of curiosity, what oral tablets did you give in the 70's by crushing, heating, and drawing up to give IV without a filter?
    Yup, time keeps on marching by for all of us. The only meds I gave in the 70s that were sent in tablet form for IM or IV use were morphine and dig. I'm sure there were others, but I didn't give them. And we never heated anything up, the tablet just dissolved on its own.

    I think there is a culture in nursing to hide our mistakes out of fear of being considered stupid or incompetent. I can certainly understand why this error occurred, and I really don't think it had anything to do with stupidity. Maybe I should have said systems error, not communication error (although it certainly ended in a med error). If the pharmacist hadn't sent the incorrect form of the drug to a nurse who had previously crushed tablets for parenteral use.... I doubt this error would have happened to a nurse who didn't realize that meds could and were safely given this way.

    I think by sharing our mistakes without judgement we can help everyone avoid the same or similar mistakes in the future.

    And that's my humble opinion.
  3. by   PicklesRN
    Quote from RainbowSkye
    Yup, time keeps on marching by for all of us. The only meds I gave in the 70s that were sent in tablet form for IM or IV use were morphine and dig. I'm sure there were others, but I didn't give them. And we never heated anything up, the tablet just dissolved on its own.
    This is interesting. I graduated in 84 and I am totally unaware (or I just don't remember) morphine or dig coming in tablet form for injection.

    Was this JUST for injection or was this an oral tablet that was used for injection? Was it the same stuff we use today?

    Were those drugs not available in injection form at that time?

    Please don't misunderstand my questions to be doubting you, I am not. I just find it interesting. I didn't know this still happened in the 70's. I really thought the practice went out somewhere in the 40's.

    Was this a sterile tablet or was it what we give today for oral use?
  4. by   Mulan
    This question wasn't addressed to me, but in the 70's, there were injectable morphine tablets which were put into a syringe and the diluent dissolved the tablet, this was for IM injection. I don't know about IV. I also worked with glass syringes and reusable needles.
  5. by   RainbowSkye
    Quote from PicklesRN
    Was this a sterile tablet or was it what we give today for oral use?
    As far as I remember it was the same stuff. I know, I'm amazed at what's changed over the past few years.

    This is off topic, but back in the 70s we hung alcohol drips and gave IM paraldehyde for DTs in the ICU. Paraldehyde was really stinky and had to be given in a glass syringe because it would melt plastic. We often gave 10cc in one IM injection. I'm pretty sure its use is contraindicated these days (at least the injectable).

    We had arterial lines that were hooked right into a regular BP manometers. Rotating tourniquets were the in thing for patients with pulmonary edema. I remember how cool it was to get automatic ones (instead of using real rubber tourniquets).

    Yeah, a lot of stuff has changed, but I think the heart of nursing has pretty much remained the same.

    Oh, and to go back on topic a bit - how do y'all handle medication errors in your facilities? I mean, is everyone required to fill out an incident report, go to committee, what? I know there is a huge emphasis on preventing medication errors these days, I just wondered how it's being handled.
  6. by   imn2nursing
    Oh you poor dear. At my hospital, it is protocol that we have to have 2 nurses check and sign each others insulin. No matter what kind, what dose. I guess I shouldn't complain.

    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.

    Oh you poor dear. At my hospital it is protocol to have 2 nurses check off and sign an insulin dose. I guess I shouldn't complain about it.

    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.
  7. by   PicklesRN
    Quote from RainbowSkye
    Oh, and to go back on topic a bit - how do y'all handle medication errors in your facilities? I mean, is everyone required to fill out an incident report, go to committee, what? I know there is a huge emphasis on preventing medication errors these days, I just wondered how it's being handled.
    At the hospital I worked at being going to the company I'm with now, med errors meant that you had to complete an incident report but nurses could not be reprimanded for them. If it was a problem they could be asked to have more CEs or some educational process could be implimented but no write ups or any other such procedure. The thinking was if a nurse would be in trouble for making a med error, she would be less likely to report it.

    If it was a chronic problem and education wasn't working it was reported to the BON and the nurse was let go. But a write up for a med error... it didn't happen.
  8. by   PicklesRN
    Quote from RainbowSkye
    This is off topic, but back in the 70s we hung alcohol drips and gave IM paraldehyde for DTs in the ICU. Paraldehyde was really stinky and had to be given in a glass syringe because it would melt plastic. We often gave 10cc in one IM injection. I'm pretty sure its use is contraindicated these days (at least the injectable).
    I remember paraldehyde and you are correct, it does smell bad. I also recall one New Year's Eve giving a patient an alcohol IV for drinking auto radiator coolant. That was the cure at the time. Never had such a patient since then so I don't know what the treatment is now.
  9. by   SitcomNurse
    It is a real shame that you gave up on nursing, on yourself. So many these days wont admit their errors for fear of reprimand. I worked with a nurse who cut the Dopamine drip in half because she didnt want to run down to pharmacy to get a new bag and she was running low. The gentlemen died 5 minutes into the next shift. That nurse still holds her licence. You my fellow nurse would be a shining example of aptitude. Transcription errors, 1 mg instead of .5 mg of meds given. And nurses saying..arent all beta-blockers the same? Whats the difference between 0.25% and 0.3%? In 14 years, any nurse can tell you, errors are made. The fact is you didnt do any permanent damage to that person, and were responsible enough to make the right judgement call for yourself and for the patient. You are to be commended for that much at least. Im sure others in nursing have lost something because they did not have you to work with.

    [QUOTE=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.
  10. by   witnurse
    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.
    I hope you will change your mind. You sound like a wonderful, caring nurse. I know some who would not have admitted to their mistake as you did. Please reconsider.We need nurses like you.
    Eeyore
  11. by   medsurgnurse
    Quote from Kudra
    actually, my worst mistake to date was pretty similar to yours, mwcia12... it was my 1st semester of my RN course and i was looking after an elderly gentleman who was due for a transfusion... we were waiting on the blood to come up from the lab and the hospital's policy was that students could not hang blood, so i went to lunch... while i was at lunch, though, the blood arrived and the RN i was working under had hung it... but as soon as she had hung it, she went to lunch as well and left the RPN in charge of monitoring the patient for a transfusion reaction...

    so, i get back from lunch about 30 minutes later and i asked the RPN for report and she said that she had checked his vitals and everything appeared to be fine... so i go into the room and do the classic mistake of focusing on the lines/machines hooked up to the patient instead of really assessing him... i stupidly overlooked assessing the site, but i asked the patient if he had any complaints or pain and he said no...

    well, 10 minutes later, the patient's son comes out to the desk where i was charting to find me... he said the patient's arm was really hurting and it looked bruised... and my first thought was "crap, it infiltrated!"... sure enough, it had... the poor man had about half a unit of blood in his tiny little arm... it just looked horrible... so i stopped the infusion, elevated the patient's arm on a pillow and called my clinical instructor... my instructor was pretty cool about it and we applied warm compresses (as per hospital policy) to the site and restarted the blood in his other arm... we explained everything to the patient and his family and they were really understanding about it all... i felt SO bad...

    to make matters worse, the RPN totally flipped on me saying that i was negligent because i was responsible for the blood, not her... i think, in hindsight, that she was worried that the mistake would come back on her because she was responsible for monitoring it while the RN was away, and the half a unit would have started infiltrating before the last 10 minutes that i returned to the floor and checked the patient... but, of course, being a student i felt like i had screwed up royally... i think that was the only time i ever contemplated quitting the program...

    anyway, i feel pretty lucky that it was my biggest mistake to date because there definitely are a lot worse things that could happen... but you can bet to this day, when i do an assessment, i start with the patient and work my way back to their lines rather than focusing on the pumps anymore!

    beth
    Actually, the RN responsible for the patient is a fault. I would never hang a unit of blood and then go to lunch. If I had to have lunch then I would have waited until I returned to start the blood. I don't know where you are, but as far as I know only an RN can hang and monitor a blood infusion. Yes, the first thing you should look at is the patient. Common policy is for the RN to remain at the bedside for the first 15-30 minutes of the transfusion to monitor for transfusion reaction.
  12. by   medsurgnurse
    Quote from nurseholly421
    my biggest mistake was second guessing my first thought and taking to long to make the right decision. at the time i was a ...medication aide in a nursing home and that night i was in the med room auditing the carts for reorders. when i came out i saw ems and i had heard nothing inthe med room. soo i went to go see what was going on and found that a res had coded.emts were doing cpr to res and the nurse in charge was standing at the door to room. i approached her to find out what had happened and she said that the aide just found her that way. i asked her if she had initiated cpr and she told me hell no i aint puttin my mouth on that thing. and a few minutes later i had asked the cna what happened and she told me what she found and that when she called the nurse she called 911 and that she just stood there lookin at pt and when the cop that was first to arrive on scene he did the same thing .the res never recieved cpr until ems arrived .had i heard anything i wouldve done it myself but what the problem is that i didnt report it right away to administrative staff as i figured what good would it do it was my word against hers. and at the time i was in nursing school so the next day when i went to class i wanted to get my teachers opinion about the situation so i mentioned the scenario to the class leaving names out.and the next day i got called into the office at work as they said that i broke pt confidentiality by saying what happened and mentioning names which i didnt what happened was that one of my classmates worked at the hospital that the patient was taken to and this was small town so was easy to find out specifics and she called my job saying i broke pt confidentiality.so when i went inthere i explained exactly what happened the night of the code and why i was talking bout the incident and that i hadnt mentioned any names.of course they didnt believe me so i called my teacher and she verified that i never stated a name.anyways the place let me go saying that i endangered the pts life by not telling administrative staff right away(i was getting ready to quit anyways so that didnt bother me)but what bothered me the most was that even after all that i had told them that happened and they had statements from cnas and police and emts the nurse was still working there. some of the cnas tried to cover up for her but all the other peoples statements coincided with mine. sooo my point is to the whole horrible ordeal is report anything and everything even the minute stuff cause in the end it will come back and bite u in the butt.by the way the pt did die and she was a full code. ps sorry bout the spelling and such just tend to get lazy when ur on the comp.
    She should have lost her license. To stand by and not initiate CDPR on a full code is inexcusable. By the way, wasn't there a bag/mask to bag the patient with.
  13. by   estrogen
    Don't they have ambu bags in nursing homes? I'm about to transition from med-surg to a nursing home and once I'm there, if they don't have an ambu bag, I'll personally go to a med supply store and buy one. :angryfire

close