Your worst mistake - page 2

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   Tweety
    Well since we're confessing. I made two mistakes that still haunt me to this day.

    I had two syringes of medication, one phenergan and one saline. I color coded them with different color needles so I would know which is which. On my way to the patient's room whom I was going to give 50 mg of IM Phenergan too I stopped to fix a beeping IV. I stopped the machine and decided he needed to be flushed. And yes I flushed him with the Phenergan. Worse I turned back on his IV, which was heparin, I entered a rate of 200 cc/hr (we had very sensitive machines back then and I must have hit the last digit twice). The man was obtunded from the IV phenergan, which worried me because I was afraid he had a cerebral bleed from too much heparin, he got about 10,000 units. He woke up a couple of hours later and was fine. The day nurse called me at home to reassure me. I was devasted and wrecked forever. That was ten years ago. We now have different pumps thank goodness.

    The other one was I left a heating lamp on a burn patient who was nonverbal and couldn't call to tell me to come take it off. It was only to be on for 20 minutes. The patient was in pain when I finally realized to come back and turn it off. Again I was devastated. That was about 10 years ago too.

    I'm shivering remembering these horrors. I've learned that no matter how busy and frazzled I am, never ever ever ever let your guard down.
    Last edit by Tweety on Apr 4, '04
  2. by   kimmicoobug
    The experience that I had that just really shook me up was when I first came off orientation on med-surg. I had a patient on BiPap with elevated BP's. I was so focused on her BP's that I just didn't see her declining resp status. Also, they assigned me a very crusty OB nurse who floated over to be CNA. She didn't get sats on any of my patients, including this one on BiPap. At the time I felt that she must know what she was doing to not get sats. No, what it was is that they don't get sats on the PP's, so it was out of her routine. So, in the morning, the day shift RT, got a sat on her and said she was about to code. Within 15 minutes at the end of my shift, she was sent to ICU, where she lived, did not code, and eventually went home.
    That taught me alot. It has taught me to be so much more assertive, to use my resources, and to not become so focused on just one piece of the entire puzzle.
  3. by   HyperRNRachel
    I'm a student and have not made any mistakes...... that is because my experiences so far have been minimal. I want to thank all of you for being brave and honest enough to post your mistakes. I now have additional information to tuck into my packed brain to help me avoid such errors. I quess my mistakes will be new ones :chuckle

    In all honesty, I thank you from the bottom of my heart for adding to my education.
  4. by   ktwlpn
    Quote from hyperstudent
    I'm a student and have not made any mistakes...... that is because my experiences so far have been minimal. I want to thank all of you for being brave and honest enough to post your mistakes. I now have additional information to tuck into my packed brain to help me avoid such errors. I quess my mistakes will be new ones :chuckle

    In all honesty, I thank you from the bottom of my heart for adding to my education.
    We all make them-the trick is LEARNING from them....OWN YOUR MISTAKES...I can not stress that enough-the ONLY way to learn is to admit that we are responsible....Don't try to cover up-that only leads to more problems.Don't focus on making excuses-just suck it up...When I was fresh out of school working in acute care I gave a pt a double dose of lasix and potassium.I was in the room when the doc told him we were going to give him huge doses of each and why...After the unit clerk took off the order and the RN covering me signed off on them I gave the meds...A stat dose and then 4 hours later a repeat of each....Seems the clerk took the order off twice and it slipped by the RN-I assumed that since (as an LPN) I was not permitted to take off orders that I was not responsible so I was not in the habit of checking my orders.........I learned that lesson-anything involving my pt is my responsibility from the cleanliness of the room and laundry to the food ....good luck in your career
  5. by   Tweety
    Quote from ktwlpn
    We all make them-the trick is LEARNING from them....OWN YOUR MISTAKES...I can not stress that enough-the ONLY way to learn is to admit that we are responsible....Don't try to cover up-that only leads to more problems.Don't focus on making excuses-just suck it up...When I was fresh out of school working in acute care I gave a pt a double dose of lasix and potassium.I was in the room when the doc told him we were going to give him huge doses of each and why...After the unit clerk took off the order and the RN covering me signed off on them I gave the meds...A stat dose and then 4 hours later a repeat of each....Seems the clerk took the order off twice and it slipped by the RN-I assumed that since (as an LPN) I was not permitted to take off orders that I was not responsible so I was not in the habit of checking my orders.........I learned that lesson-anything involving my pt is my responsibility from the cleanliness of the room and laundry to the food ....good luck in your career

    Excellent advice. I've never been afraid to say "I don't know", "I'm wrong" or "I made a mistake". I worked with a nurse whom we suspected gave some BP meds to the wrong patient, and the patient wasn't hers. The patients BP bottomed out and had to be given fluids rapidly and was fine. The patient even described the nurse who gave the meds, giving an adequate description. She even went into the room with me and looked the patient in the eye and said "I've never seen you or been in here, you're confused."
    Scares me that there are people out there like that taking care of patients. :angryfire
  6. by   heart queen
    Now, i'm sure not my worst mistakes, but last night alone, call from the day shift nurse just two hours ago, two meds I forgot to give. doesn't seem that bad, one NaHC03, one coumadin. But I've been nursing fo 9 years.

    Went into work last night with only 3 hrs. of sleep off the prior night. Couldn't sleep.

    It still happens is my point. could have called in.. yes, but we keep on guilting ourselves.. okay I guilt myself, How can I can I call in when wer're short just because I couldn't sleep...... look what happens.

    Almost fell asleep driving home, missed two meds.

    Morale... 9 years in and still making them.... own up to them and learn. I just never spent the time RECHECKING the MAR. Both were new orders around shift change.... I just signed off 24 hr. checks because I was sooo behind. Due to sleep deprivation... my own fault.
  7. by   featherzRN
    Everyone makes mistakes, it's best to just fess up and learn from them. I had one the other day that turned me crazy-there was little chance of harm to the patient but I had visions of piles of med error paperwork, meetings, etc etc etc. :P

    We're an outpatient clinic and give Procrit to various patient - some are renal patients and require special instructions, the rest are not. The 'special' patients are kept in a folder so we can keep up with their orders. This gentleman (Mr. X) walks in with his shot card - I look in the book and see no 'hold' order, so I go ahead and give it. I tell him he is due to take his CBC next week, so don't forget!

    I'm looking through the book to see if anyone else's shots are coming due, and what do I see? A hold order for Mr. X! It's stuck in with another patient. Yikes! I leave a message for the patient's doctor and I am on pins and needles waiting...

    "Hello? Featherz? This is Dr. Y. Can you call Mr. X to tell him he needs his Procrit shot today? I am sending over the orders!". ROFL! And /Whew! I did fess up to the doctor and he thought it was very amusing. Apparently Mr. X had decided to take his blood tests a week early and that saved me from an incident report.

    Then there was the time I hooked up the oxygen mask to the 'air' plug after extubating a fresh open heart. :P That mistake was noticed within minutes, the patient was fine and my old coworkers still tease me about it. I have no memory of doing this, but I am being teased about it 10 years later so I guess I must have done it.

    Featherz
  8. by   ktwlpn
    Quote from 3rdShiftGuy
    Excellent advice. I've never been afraid to say "I don't know", "I'm wrong" or "I made a mistake". I worked with a nurse whom we suspected gave some BP meds to the wrong patient, and the patient wasn't hers. The patients BP bottomed out and had to be given fluids rapidly and was fine. The patient even described the nurse who gave the meds, giving an adequate description. She even went into the room with me and looked the patient in the eye and said "I've never seen you or been in here, you're confused."
    Scares me that there are people out there like that taking care of patients. :angryfire
    eww.I have been there,too...Luckily for our pt my co-worker realized right away that she had given the wrong meds and came to me at the desk..We called the doc-he blew us off....Our guy bottomed out within 2 hours (I looked up all of the meds and knew exactly when it was going to happen so we were ready) so we had to 911 him out of there-He had no b/p when EMS got there...He spent the night in ICU and recovered...Tough old bird-94 yrs old...The med nurse was devastated.Our admin treated her with sensitivity....She learned an important lesson that day and changes were made on the unit-2 med nurses from then on.........But-if she had been another kind of person that fella would have died and we would never have known why ....
  9. by   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.
    It seems that the more I practice, the more I feel helpless. I am glad I have had this time off. I am hoping that I will be more energetic, more caring, more aware of my patients needs and more assertative in getting the needs met when I go back to work.
    Another thing I have decided, NO matter how good the money, if I don't "feel" right about the job, then I am going on down the road. I have spent too many hours working in positions that were not a fit for me just because I had to pay bills and support a family. I hope this makes sense to some of you "oldtimers" and gives an insight to "newcomers". We all make mistakes, hopefully, we do as little harm to patients as possible when we do, and we are honest and own up to those mistakes. I pray each day that I will be a benefit to those I take care of and not a danger. Thanks for giving me this opportunity to be honest about how nursing is for me these days.
  10. by   sharann
    Hopefully this was my worst mistake since its the one that flashes every time the term med error comes up. I was new in recovery room and just barely a year out of school anyhow and my experienced co-worker asked me to give a pt their post-op coumadin(which is standard for a certain doc on certain procedure). So instead of CHECKING the order I gave the dose. Later, as I was checking orders I found this: "Give Coumadin AFTER epidural catheter removed". Stomach drops to floor.I am hot, sweaty. Call the anesthesiologist who says "Oh crap", then says thank you for being honest and don;t worry, take out the catheter and check the site often(coumadin is slow acting so he was not too worried...I WAS!).
    So, I refuse to EVER give a med to a pt I have not seen the order for.Lesson learned, patient o.k.
  11. by   leslie :-D
    the worst and most STUPID mistake was doing count (narcotic) with myself at 10:45pm. the other nurse witnessed me doing it; she was in a bad mood so rather than 'bother her', i just did count by myself. the count was fine but the noc nurse reported it to the DON. i absolutely had no excuses. stupid, stupid, stupid.
  12. by   nursedawn67
    My biggest mistake was.....

    in a LTC facility that I worked at several years ago, the midnight nurses did the morning fingersticks and the day nurses gave the insulin based on the FS that the MN nurse got. So that particular morning the day nurses were "staff challenged" and we decided to give the insulins for them, since breakfast was not that long away. So I gave the required insulin for one resident and charted it in the MAR and then specifically stated in my taped verbal report that the insulin HAD been given. Several times I emphasized it. Well the day shift didn't bother to listen to report and gave the insulin again...my mistake was when I signed the MAR, I signed the wrong time. I gave the right dose for the morning dose, but signed the evening dose...so when the day nurse went to the MAR she gave the AM dose. then she listened to report and realized it had already been given and that she gave the second dose. I never got wrote up, and the resident was ok, and her family was really cool they said "your only human, things happen, shes ok". You better believe I double check double check double check!
  13. by   PMHNP10
    3 mos as a nurse and I have a 60 y/o pt. who is in for kidney stones, but has a long Hx--l sided palegia from CVA, diabetic, dementia (and he was actively hallucinating while I had him); also, he wore a CPAP at night. This was my second night with him, and it was after his stone removal procedure. First, some time after midnight, his wife called saying he was having trouble breathing, so I called RT and he told me the CPAP was not on correctly.(0440) he was in pain, so I gave him a couple vicodin. About 40 min later he was trying to get out of bed to answer whoever was knocking on his closet door, so I gave ativan 2mg IV. At about 0600 I started to do my final rounds to reset IVs and make final checks. To this day all I can say is that all appeared to be ok. At 0730 I should have been home, but I stayed for an inservice for the hemovac when I hear those horrible words over the speaker--code blue, room 420...I jet outta the room to see them performing the full code. I saw they didn't have anything to take a temp, so I ran and got a tymp thermometer--91.4. He wasn't coming back. Next I went to the bathroom and sobbed. Before I went home, I spoke with the NM, day charge, the minister, and the wife (who was there the entire time). I couldn't get the thought out of my mind that maybe at 0600 he wasn't really breathing; maybe if I would have stayed just a moment longer and been certain, we could have saved him if he hadn't been breathing. Also, I kept thinking, maybe the combo of drugs I administered gave him the extra push over the edge. And to add, the wife was questioning whether anyone ever checked when she called about her husband having trouble breathing. And if things weren't bad enough, I hadn't charted when RT checked him, and had forgotten the time he readjusted the CPAP, so when I charted after the fact, I most certainly put the incorrect time. Despite what everyone was saying, I knew my license was a thing of the past. And worst yet, I didn't even have any legit defense, because my charting didn't support my efforts if any kind of lawsuit/charges were to come up.

    ***Lessons Learned--When I enter a room, no longer do I think all is ok; I don't leave until certain. Also, chart when it happens, or immediately get it onto paper for future reference. I believe I didn't cause his death by my actions, but to this day I can't help but have the least doubt about whether he was breathing or not. But by the grace of God, I will not allow such a situation to occur again.

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