Your worst mistake - page 22

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
    Quote from Bipley
    A bit of an attitude issue, don't you think?
    To say the least
  2. by   goats'r'us
    my error is going to sound like no biggie compared to some other people's, but it'll be a cold day in hell when i forget the lesson learned..

    had a patient who was a not-so-compliant diabetic, QID BSLs, sliding scale actrapid and nocte protophane. took her BSL at 2030, then took her chart to the fridge to get her insulin. We were short staffed, so the supervisor was helping out on our ward, and i grabbed her to check the insulin and chart with me (policy at my hospital). while drawing up, talked about whether you draw up clear or cloudy insulin first, then went off to the bedside to dive the insulin. told the patient i had her insulin, and she uttered the time-honoured words 'there's a lot in there, isn't there?' to which i explained that this was because i had both doses in the one syringe. gave the needle, went on with my business, went home.

    overnight, i started thinking about it, and thinking 'was that a QID sliding scale or TDS?', but comforted myself that the very experienced supervisor had checked with me, so even if i'd made an error, she'd have looked at the chart too and would have noticed it. relieved, i went to sleep.

    next morning, had an early shift and was assigned the same patients as the night before. checked this lady's BSL, and once again went to the fridge with her chart and the nurse i was working with. opened her chart, and there in front of me was her TDS actrapid sliding scale, with my extra dose neatly signed for, complete with 20 u/s written underneath so people could see what dose had been given.

    started in with a chorus of uh-ohs, and pointed my mistake out to the nurse i was working with. she looked around, made sure no-one was listening, then asked me what the pt's BSL was. told her it was 5.something, and she then proceeded to tell me not to say anything, as the lady was clearly fine and it wasn't worth getting myself in trouble when probably no-one would notice. she even recommended that i cross out my signature on the chart and write error on it, as if i'd written it in, realised my mistake and not given it.

    i was very keen not to get into trouble, and was so embarrassed that i'd screwed up just when i was starting to find my feet, but deep down i knew i'd screwed up and it'd bother me till i dobbed myself in. luckily, the cnm was away that day (she made me a little bit nervous), and the nurse in charge was possibly the kindest person on the face of this earth. i grabbed her in the hallway, and got as far as 'can i talk to you for a sec' before bursting into floods of tears.

    after calming me down by telling me about times she's screwed up (with the help of an orderly who chipped in by telling me about his army days when he screwed up in a huge way in front of his biggest, meanest boss), she got the whole story, told me i'd dome the right thing telling her, reassured me that the patient would be fine and that these things happen, and helped me fill out an incident form, which i don't think she even forwarded to the cnm, but which made me feel miles better.

    i got to go home that day rattled but feeling that i did the right thing, and i certainly learned my lesson. your eyes may think they see something on a chart, but then, sometimes people's eyes think they see dancing babies!
  3. by   jen42
    The error another nurse told me about when I was crying on the BMT floor as a new nurse will always stick in my brain...

    She was transfusing some blood, and it just wouldn't tranfuse at all. She slowed and slowed the rate, but no go. Finally she put a blood pressure cuff on the bag to force it in.

    Well, the reason it wouldn't go in is that it wasn't hooked up right to the IV. So the connection fails, and blood starts spraying all over the walls, all over the patient, all over her. It's everywhere. The DON was walking by. She came in to find the nurse repeatedly wiping down one spot of a bedrail over and over again with a cloth, and blood flying around the room.

    They finally clean everything up, including the blood-soaked patient who is an elderly Japanese man, sitting calmly throughout the whole thing.

    The next day she walked into his room, and he smiled and said in a thick accent "Ah! The nurse with the blood. No blood today."
  4. by   LoriAlabamaRN
    I am so glad to have this thread... it has really given me some "heads up" advice as far as what can and cannot be allowed to happen and what must be watched closely. Thank you to everyone who has posted- any more?
  5. by   LoriAlabamaRN
    Sorry- duplicate post
  6. by   HeadGames
    Quote from 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.
    "...my schiz patient..." Really? Please rethink your labeling of patients. It is really demeaning :stone.
  7. by   southern_rn_brat
    I'll never forget my first one either. I was only about a month into my 1st job and had a patient ordered Augmentin. His wife was in the room as I was giving it and says "He's very allergic to pcn" I say "oh dont worry this is augmentin" and as he starts to swallow I realized what just came out of my mouth but it was too late. His last reaction to pcn had been a true anaphylactic reaction . omg I started crying right then and there and I continued to cry as I called the doc, the DON and anyone else I could think of. I refused to leave his side that evening. He and his wife ended up consoling ME lol. I beat myself up over that for over 6 months until the DON had a talk with me and told me I HAD to let it go and move on. I didnt think I deserved to be a nurse.

    Last Febuary I discharged a patient and made an error and put tegretol on his dc orders. About a week later his dialysis clinic called and I just so happen to be the one they talked to. They wanted to know the diagnosis we had for putting him on that for their records. The doc was in on rounds at the time and she looked thru his old chart to find out for me. She said " look at this...some IDIOT made an error on his dc orders" I rolled my eyes and said "omg who was it" and she laffed and said YOU. He had no adverse effects from it luckily since he was on dialysis. I have spent a few hours with risk management though because not long after I personally called the family and admitted my error, we got a letter from a tv lawyer
  8. by   Keysnurse2008
    MWCIA12,
    Just learn from your mistake. Never hang blood or anything thru a pressure bag unless that patient is crashing on you.If it cant be run thru a pump at 999 / hr without alarming then there is a major problem.That IV is either infiltrated...too small for the solution - and it is going to infiltrate-it will!...or you have 2 solutions incompatibly mixed and it doesnt NEED to go in. Either way....you never need to force it in, check for blood return.No blood return= start another IV when it is blood you are trying to infuse.
    A few months ago....I was asked to come look at an IV site for another nurse.This nurse had "forced" a extremely irritating solution in.When I entered the room....it was 30 minutes after her and her cohort had "squeezed" in the last drop. The patients hand was cyanotic on the palm...and you could literally watch the discoloration advance. I got physicians in to look at it,..placed a kpad on it....and assisted the nurse and physician. No matter what we did, or the physicians or the plastics team tried it didnt help. The patient died the next day bc of the initial injury she came in with......but if she hadnt....she wouldve lost the arm from the elbow down. Scared the 2 nurses involved to death...which is really good.Same as you....you will not ever want to see that sight again huh? There is a set of standards that IV therapy nurses and all nurse have to go by...I cant recall the name...but if you typed in "IV therapy guidelines" youd probably find it. Live and learn from this. How did the site look the next day?
  9. by   LoriAlabamaRN
    Quote from rvideto
    "...my schiz patient..." Really? Please rethink your labeling of patients. It is really demeaning :stone.
    I don't think any harm or "demeaning" was meant. She was simply clarifying the patient. We can't exactly give names. I've often said "my hip patient" or something similar. It's meant as a descriptive factor, not a demeaning one.

    This thread is one in which nurses are telling deeply personal situations where they have made a med error. Can we focus on that and not on petty dissections of the posts?
  10. by   Bipley
    Quote from LoriAlabamaRN
    I don't think any harm or "demeaning" was meant. She was simply clarifying the patient. We can't exactly give names. I've often said "my hip patient" or something similar. It's meant as a descriptive factor, not a demeaning one.

    This thread is one in which nurses are telling deeply personal situations where they have made a med error. Can we focus on that and not on petty dissections of the posts?
    Once again, we agree.
  11. by   NurseNili
    here's a few of the mistakes i have made in my illustrious nursing career: not getting enough sleep between shifts and being dead tired at work, which distorts judgment and critical thinking skills; mistaking "unit" for "cc" (read: gave wayyyyyy too much insulin iv", accidently infused an entire litre of ns into an 18 month old child, while trying to clear air from an iv pump and running it wide open to feed the saline through (new infusion pumps have helped eliminate that mistake), mistaking a bbb for v-tach, and precordial thumping someone who was awake and alert (can we say duh????), instilling "antibiotic" eye drops into an 8 year old child's eyes, only to discover that i grabbed the wrong bottle and instilled pupil dilating solution into her eyes (always remember that a red capped bottle of eye drops indicates "dilator", a helpful hint from my opthamologist), giving 10 mg of calcium chloride ivp over 30 seconds for a patient with a high k+, all the while watching the patient's rhythm go from nsr to sb to asystole, and not recognizing that this was happening, before a co-worker ran into the room and administered atropine (the patient lived, but i just about died, and now i give calcium chloride ivpb over 10 minutes), do i need to go on?

    point is...you can make mistakes and still be a fabulous nurse, as long as you learn from them and never do them again. i am very fortunate to be working in a facility that has a non-punitive med error policy...they always say "it's a system error". gotta love that, but actually, it usually is, it is almost always not just one person's fault, there are usually contributing factors for pretty much every situation. my excuse? as an er nurse in an ed that sees over 200 patients per day, many with high acuities, i am always in a hurry, but taking 10 seconds to check myself for critical errors has prevented me from making more mistakes...don't let any nurse tell you that they have never made mistakes. every one of us has, to error is human, right?
  12. by   Marylou1102
    I've been a nurse for 35 years and I've made my share of med errors and I've seen others do the same. The worst error I ever saw was made by a Doctor. I was still pretty new to nursing and had never worked in the ER or had any real experience with cardiac patients. So of course one night I get pulled to the ER where I am the only RN, and the ambulance brings in a gentleman in full cardiac arrest. In the room was the doctor, 3 EMTS (to get in the way), the LPN, the night shift nursing supervisor and me. During the code Doc asks me to get a particular cardiac medication. I don't remember what it was now. As taught I repeated the order and dose back to him which he confirmed. The supervisor was already in the alcove pulling out the meds and told me we only had half the dose needed. I thought that was odd because we had counted all the drugs when I came on and were fully stocked. I was told to go to the ancillary pharmacy and get the rest of the dose anyway. After the supervisor drew up the medication she gave me the syringe. I took it to the Doc and again repeated the med and dose. He indicated that I should give it IV push. I told him I couldn't give it so he did. The patient was not revived. About 2 days later I got a call at home from the hospital administration. They were questioning the drug and my giving it. I told them I didn't and why, and that the Doc gave it. I was really afraid that they were going to try to pin it on me. Turns out that the dose was more than 10 times what it should have been and that was what killed the poor guy. I never heard what happened to the Doc or the supervisor, if anything.

    The point is never be afraid to follow your instinct, never be afraid to refuse and know your nursing protocols.
  13. by   Gompers
    Quote from Marylou1102
    The supervisor was already in the alcove pulling out the meds and told me we only had half the dose needed. I thought that was odd because we had counted all the drugs when I came on and were fully stocked. I was told to go to the ancillary pharmacy and get the rest of the dose anyway.

    Turns out that the dose was more than 10 times what it should have been and that was what killed the poor guy. I never heard what happened to the Doc or the supervisor, if anything.
    That's a good story - always pay attention to things like that. You hear stories about that all the time - a nurse taking a bunch of vials to draw up one dose of medication when you usually would only use like half a vial per dose, etc. If you ever have to call pharmacy to get MORE of any kind of med, make a mental note to double, triple, and quadrouple check what you're giving.

    I'm glad you had the doc give the med instead of doing it yourself.

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