Your worst mistake - page 19

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   BORI-BSNRN
    Quote from hotmama
    The unit I work on is a oncology unit, although we also get medical pts as well. We had a new RN that had been pulled from another floor on night shift, and she was assigned a pt who had been on our floor 2 days. This pt was in for etoh abuse, and had been going through DT's, and was recieving ativan iv. He had not slept for days. The nurse also had a ca pt who was receiving dilaudid for pain control. She had drawn up in two syringes the ativan and dilaudid to save time, and gave the dilaudid to the etoh pt by mistake. The pt went out, but was breathing. All night the pt slept, and the nurse didn't take vitals or disturb the pt because the charge nurse on nights told her to not disturb him since he had not slept in days. The new rn had tried to wake him, but he would not wake up. When The narcotic count was being done, it was discovered that the nurse had given the wrong med to the wrong pt. Still no one checked on this pt. When we got out of report for day shift, I went in to assess this pt and I could not wake him up, not knowing what had happened on night shift because it was not passed on in report and the night nurses had already left, The pt sat was in the 50's, and had probably been there for a long time. The New rn, and the assistant nurse manager both lost their license. The pt is a vegtable still in our hospital, not on our floor of course.

    Ohhhh my God, what a nightmare!! :stone
  2. by   chadash
    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 am so sad you left nursing! How long ago was this?
  3. by   jhowirn
    ....& my second worst mistake was accepting a position from my now former employer. Don't guess it would be very professional of me to mention the name of this facility? Anyhoo, to touch up the resume....
  4. by   LoriAlabamaRN
    My worst (only) med error was when I was a couple of months out of school. I was so careful all the time (I thought). One night I was taking the orders off of a chart and I misread one. The order was for Desyrel and I read Seroquel. The physician's writing was very messy, but that didn't excuse the error. When I found out the next day, I will never forget the feeling, like being stabbed through the heart with an icepick. I was terrified that I had hurt the patient somehow. Luckily, he didn't have any lasting effects. It turns out they had tried him on Seroquel a few months prior but DC'd it because it made him too lethargic for therapy. Other than him being very drowsy (and napping in his room rather than going to therapy) there was no harm done. I will never forget that fear, though. I pray that I never make another med error.

    Lori
  5. by   LoriAlabamaRN
    When I was just starting as a graduate RN, I had a charge nurse who acted like I was a brand-new nursing student or something, constantly making sure I knew what I was doing. And I don't mean in a preceptorlike way, I mean in a way that was pretty insulting ("You DO know that the insulin you're about to give is to be given sub-Q, right?" "You DO know you can't inject air into the IV when doing a flush, right?"). This went on for over a week, even though I had not made any mistakes and had not given any reason for such poor confidence in my nursing abilities. One night I decided to tease her- I had a patient who got Tylenol elixir because of trouble swallowing pills, and I went to give it one night ("You DO know that since the elixir is 250mg/cc then to give 500mg you give 2ccs, right?"). When I came back she said "Everything go alright?" I said, perfectly straightfaced, "Yes, he said he didn't like the taste so I gave it IV, that's ok, right?" OH the look on her face- priceless. When I laughed and assured her that I was teasing, she laughed her head off and said that she knew she'd been talking down to me, and that she deserved that. We ended up becoming very close friends.

    Lori
  6. by   nurse_clown
    Quote from lorialabamarn
    when i was just starting as a graduate rn, i had a charge nurse who acted like i was a brand-new nursing student or something, constantly making sure i knew what i was doing. and i don't mean in a preceptorlike way, i mean in a way that was pretty insulting ("you do know that the insulin you're about to give is to be given sub-q, right?" "you do know you can't inject air into the iv when doing a flush, right?"). this went on for over a week, even though i had not made any mistakes and had not given any reason for such poor confidence in my nursing abilities. one night i decided to tease her- i had a patient who got tylenol elixir because of trouble swallowing pills, and i went to give it one night ("you do know that since the elixir is 250mg/cc then to give 500mg you give 2ccs, right?"). when i came back she said "everything go alright?" i said, perfectly straightfaced, "yes, he said he didn't like the taste so i gave it iv, that's ok, right?" oh the look on her face- priceless. when i laughed and assured her that i was teasing, she laughed her head off and said that she knew she'd been talking down to me, and that she deserved that. we ended up becoming very close friends.

    lori
    [font="impact"]i like that one. you handled yourself well. i'm going through something similar that's getting more frustrating. reading your story has helped.
  7. by   perfectbluebuildings
    Last night was a big mistake for me... I feel terrible. I had a very active little baby, sitting up and able to crawl and stand, whose mom was already kinda anxious and upset about some other things that had happened. She asked me to change his IV armboard cause he'd been eating and got some food on it, and so I got the side rail of his crib down and stood in front of him tearing tape. He reaches for my tape roll, tips forward, and before I can catch him he has fallen head first straight into the bedside chair. I thank God that chair was there and he did not hit the tile floor- I shudder to think what the outcome could have been and all my fault for not catching him. It was the most awful feeling!!! The baby had fallen once before during his admission, and now will have two knots on his little head. This was early in the shift and you can bet the rest of the night I kept a very tight hold on this kiddo whenever I needed the rails down to do ANYTHING!!!
  8. by   GLORIAmunchkin72
    When I was brand new passing meds about a year ago I had to pass my meds at a furious pace. I had two full carts to pass simultaneously yet I had to be time compliant and still expected to run after alarms and answer call bells. It was a very dangerous setting. Thank God they have lightened my load since then...
  9. by   PamUK
    I'll tell you my worst mistake was about 18 years ago. I was working the evening shift on a chemo ward. A fairly new doctor had prescribed the chemo (100mgs cosplatin) and the pharmacy had mixed it up. I knew the dose was incorrect according to the protocol so contacted the patients consultant, who came & changed it to 200mgs. Since it was after 6pm, & pharmacy had closed, I had to add the extra 100mg myself (nurses could do that in those days) which I did around about 8pm. The ward was furiously busy & as I finished the mixing, one of the nurses put out a cardiac arrest call. I naturally went to the call, finished my shift at 9pm & went home, completely forgetting that I had not changed the label to indicate that the additional cisplatin had already been added.

    Enter the night shift... they noticed that the script said 200mg but the label indicated 100mg & added a further 100mg, making a total of 300mg

    For those of you who have worked with this drug, the consequences are renal toxicity, severe nausea & vomiting and ototoxicity, to name a few. That poor man had puked all night long, and the staff had given him everything to relieve his N&V (Kytril & Zofran had not been discovered at this point) His renal function according to his lab work was a mess and he had constant ringing in his ears and ended up with permanent partial hearing loss.

    I owned up the very next morning, as soon as I realised my error. My manager was brilliant, the consultant was brilliant and the patient was brilliant. I feel sick every time I think of that error
  10. by   coolwater
    I praise you that u admitted your mistake...This types of mistakes should be shared so others remain alert in their practices at clinical area.
  11. by   jwhitern
    After reading all of these posts I am thankful that my biggest mistake to date is more embarrasing than life threatening. It was my first week as a GN at a teaching hospital. My preceptor was very comfortable with my skills and decided that I was more than capable to deliver meds without her. She would be in the nurses' station (playing games on the computer) if I needed anything. Well, with a swelled head from the compliment, I proceeded to give my 6 pts. their medications. I get to Mr. X and start collecting his meds and notice that he is to receive " two sprays PR" of this Hurricane Spray. I'm thinking to myself, why would be "spraying" his rectum? I go ask the RN (who is having a ball in the nurses' station) and show her the order. She confirms the order and , stupid me, doesn't ask why?

    I go into Mr. X's room and explain that I have to spray his bottom. He gets up, doesn't ask why? and leans over the bed. I spread his "cheeks" and give him 2 large sprays. Well, he starts dancing around and waving at his behind and tells me that it's burning and can we wipe some of it off. I say sure and give him some tissue. He finally settles down and I go off to the next pt.

    About an hour or so later, I still can't understand why we would give this guy butt spray. I take the can and go to the pharmacy. They tell me that it's Hurricane Spray and it's for the throat. (Duh??!! My guy has an NG tube). The order should have been PRN and the unit clerk misread the order. I am mortified. I go to the RN and explain the situation. She laughs and says to give it PO. I can not tell this poor guy that I just sprayed his *** with spray that was intended for his throat. So, I play it off, " Guess what Mr. X, the doctor has ordered another spray and this one's for your sore throat!"

    I could barely tell my husband what happened that night, I was laughing so hard. This guy probably warned his friends not to go to that hospital, "they spray your ***!! Bet he wondered why it wasn't on his bill. Compliments of the nursing staff.

    This taught me to trust no one when it came to delivering meds.
    Last edit by jwhitern on Nov 8, '05
  12. by   LoriAlabamaRN
    At the hospital I used to work in, we had an RN who made a pretty drastic med error... on herself. Here's the story:

    She had laser eye surgery to correct her vision, and decided to go to the beach that weekend with her family. At the hotel, she went to get her eyedrops out of her overnight bag...and grabbed a bottle of superglue instead. Yup, drop of superglue straight in her eye. In pain and scared, she had her hubby call paramedics (her eye at this time was glued completely shut.) Apparently she knew that nail polish remover (acetone) removes super glue... so yup, rubbed nail polish remover into her eye while waiting for paramedics. Long story short, she had to have the surgery all over again and she probably won't ever live it down. (Thank God though, she didn't lose the sight in that eye).
  13. by   GLORIAmunchkin72
    Some mistakes are not med errors. A few years back this one CNA co-worker told me about that sick feeling she had when she realized on her way home that she had left someone on the toilet. She hurriedly returned to the facility to find the resident still sitting on the toilet. She said she just felt sick and was glad the resident was ok ( except for a nice ring on her bottom).

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