Your worst mistake - page 20

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   LoriAlabamaRN
    I think this thread is incredibly valuable- it has given me a brainload of things to watch for, and consequences that can happen if I don't. Thank you everyone for sharing! Keep them coming!

    Lori
  2. by   Jessy_RN
    Not finished reading the entire thread but very interesting. Thank you all for sharing.
  3. by   Alibaba
    Ok...this is NOT a worst mistake, but it was a wake up call for me. Yesterday an A&O resident went to hospital on day shift. came back about 4pm. did my assessment on him (he's COPD non compliant with tx), so my assessment was focussed on resp/cardio. did my 9pm medpass and about 10pm he calls me to ask if I can take his foley out. am like "am sorry, do what??"" he had come back with a foley and I completly missed it. I mean I missed the big ol' bag hanging from the bed, the long tubing going down the side etc... and it wasn't even a busy day for me. It just made me stop and reassess everyone. man it made me feel aweful
  4. by   HappyJaxRN
    Quote from BabyRN2Be
    As a student-to-be, my worst fear is making a medication error. I haven't even started school and I've been reading chapters in nursing books about drug calculations, and I practice these calculations when I can. I can see myself as a nurse triple, quadruple checking to see if I've got the right medication, delivery route, right dose, and most of all, right patient!
    Hi there. Unfortunately, to err is human. When you feel overwhelmed, stop, take a deep breath and get your thoughts reorganized. I do this now. I take about 5 to 10 minutes to figure out what is needed...I get my thoughts organized. I make sure I know what needs to be done. I would rather stop and do this than jumping in head first and making a mistake that could harm my patient. If I can't stop for whatever reason, I summon help.

    It's gonna happen. Mistakes. And when it does, don't beat yourself up over it. I know I did. I need to eat my own words. But it's true. Everyone makes mistakes. Good luck with your schooling.

    Oh and one other thing...when you DO make a mistake, I can say most likely, you will never make that same mistake ever again. It makes an impression on you that you'll never forget. :wink2:
  5. by   HappyJaxRN
    I'll have to say that the worst mistake that I've made is I ran Amphotericin in with a pre and post flush of D5NS. Ampho is to be flushed with only D5W...ONLY! Or so I'm told. When Ampho and NS mix, it crystalizes in the line. Needless to say, I called everyone under the sun that night to make sure my patient wasn't injured from my mistake and he wasn't. It was a $2000 mistake and I occluded one of the lumens on his picc line...that scared me to death! What a horrible feeling.

  6. by   LoriAlabamaRN
    Quote from HappyJaxRN
    What a horrible feeling.

    that feeling is unforgettable... like being stabbed through the heart with an icicle. I pray I never feel it again. But I will say, I sure as heck learned something, and that won't be forgotten either!
  7. by   Serenyd
    New nurse - gave a lortab to a women with a HA - on a PCA PUMP!! I had to call the anesthesiologist and tell him what I'd done and ask if I needed to fill out an incident report.. so embarassing. Ended up having to fill out the incident report but the doc was really nice about it. Most of the mistakes I've made happen when I'm stressed, rushed and overtired.
  8. by   Bipley
    This likely isn't my worst but it is what comes to mind. I had a patient that would cheek his meds. He was a psych patient. The doc ordered Thorazine Concentrate Liquid. At least we could have a better chance of knowing if he was taking his meds.

    Regardless of what I put the concentrate in, it was amazingly bitter and beyond horrible to get down. I finally put it in milk. As usual, my schiz patient drank it down.

    I had NO idea until I saw the bottom of the cup that the milk was curdled. Thorazine concentrate CURDLES milk.

    As I saw the bottom of the cup I must have apologized 10 times! I felt horrible, I made my patient drink curdled milk!

    To this day he is one of my most favorite patients. He told me he didn't mind, he knew he was wrong for not taking meds to keep him from being psychotic. He KNEW the milk would curdle, I had no clue. That made me feel even worse.

    It wasn't technically a med error, but yet it was. He understood I was merely trying to find a way to cover the horrific taste of Thorazine concentrate. He, the mentally ill patient, appreciated my efforts to find a more pleasing way to take his meds. I, on the other hand, felt like a dog.

    One time when I was working 2-12's in a row (ICU patient, couldn't just leave him alone and everyone called in sick) I had a patient with a simple foley. I was exhausted and could no longer think. I went to inflate the balloon to keep the foley in place and it ruptured. It only took 5cc of air, not 25. I have NO clue where "25" came from, but that was what I was thinking.

    The guy was a schizophrenic and they don't experience pain as the rest of us do. That was my only saving grace. The guy's bladder was plum full. Thus, the need for a foley. His reaction... bug eyed.

    I flat out refuse to do 2-12s in a row. If they don't have coverage they need to tx the pt to a different hospital... one where they have fresh nurses. Understand, I am NOT blaming the hospital. I blame myself. I KNOW better than to work 2-12s in a row.
  9. by   Simba&NalasMom
    Quote from MelissaRN
    At my hospital year before last there was a nursing student that made a mistake with Heparin. Not sure exactly what happened but it was a serious mistake. The school that she was going to permanently let her go from their program. When the hospital found out about it they went to bat for the student and told the Dean of nursing there that if they didn't reinstate her that they would no longer accept student for clinicals there. They felt that it was human error and that she should not have been dismissed.
    So was she reinstated? Kudos to the hospital.
  10. by   hotmaleRN2b
    Quote from Berta
    As a student, I know that I WILL make mistakes. I applaud you for realizing and admitting your mistake. We all make mistakes..The single most important thing is that we learn from it and don't repeat it again.
    Berta

    Nobody's perfect! or so they say... But i honestly believe that in our profession, in which evry action we take has bearing on the safety of life of another individual - THERE SHOULD BE NO ROOM FOR ERROR ... That is why it is important to check and recheck... I really hope you learned from it, and i hope that next time, you will learn without putting the client's safety at risk..
  11. by   sjrn85
    Quote from hotmaleRN2b
    Nobody's perfect! or so they say... But i honestly believe that in our profession, in which evry action we take has bearing on the safety of life of another individual - THERE SHOULD BE NO ROOM FOR ERROR ... That is why it is important to check and recheck... I really hope you learned from it, and i hope that next time, you will learn without putting the client's safety at risk..
    Wow...are you an RN yet or a student? One thing you need to learn, either way, is that everyone makes mistakes. Your comment demonstrates a naivete that is dangerous.

    Come back after you've been practicing for 10y and try to say you never made a mistake.
  12. by   hotmaleRN2b
    Quote from sjrn85
    Wow...are you an RN yet or a student? One thing you need to learn, either way, is that everyone makes mistakes. Your comment demonstrates a naivete that is dangerous.

    Come back after you've been practicing for 10y and try to say you never made a mistake.
    Im not saying i wont make any mistake... But i really hope i wont... There are ppol's lives on the line here and im being paid to give them quality health care and that includes insuring that i give the most care i could give... I hope you are getting my point
  13. by   Kalico
    Quote from hotmaleRN2b
    Nobody's perfect! or so they say... But i honestly believe that in our profession, in which evry action we take has bearing on the safety of life of another individual - THERE SHOULD BE NO ROOM FOR ERROR ... That is why it is important to check and recheck... I really hope you learned from it, and i hope that next time, you will learn without putting the client's safety at risk..
    I wonder if you are a student or are actually out there practicing. If you are a student you need to be careful because everyone makes mistakes at some point in time. You are not immune. If you never make a med error in your life, then reviewers may wonder about it because at some point in time you will be struck with the "error disease" that strikes every human at some point in time. That does not mean that we shouldn't be careful but mistakes will happen.

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