Your worst mistake - page 27

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   bethin
    I can't remember if I posted in this thread or not but anyway:

    I was feeding an elderly pt lunch. I moved to her bedside table to get her hearing aides when my foot became entangled in something. Figured it was the phone cord 'cause those suckers are 50' feet long. Try to shake it off my foot. Wasn't the phone cord. It was her IV and I had yanked it out her the poor lady's arm. Felt horrible. So I go up to the nurse and tell her so and so IV's out. Didn't tell her I did it, although I know now I should have. I would have if the nurse wasn't a complete and utter *****.
  2. by   augigi
    Quote from Pepper The Cat
    OK - I really need to tell someone this. I am feeling sooo sick right now.
    I think I gave my pt a drink of urine. yes, urine! All day, I've been caring for a pt who is confused, periods of aggression, etc etc. he likes to drink a lot of ice water, so I made sure all day that I had fresh ice water on hand - not easy because he is also in isolation. Just before I left today, I went to check on him, he was a little restless and wanted something to drink. So I grapped the cup of water I put there at supper. He took a sip (a very small sip!) and said 'that tastes funny" - I opened the cup and looked in, it was a yellow fluid. I thought maybe another nurse brought in apple juice when she brought in his HS snack (even though I told her not to disturb him and it was too early to bring in an hs snack) but as I dumped it (because he didn't like the taste) the smell hit me. It smelled like, well, pee-pee. The other nurse denies bringing in apple juice, but then kept diveting to how "I didn't wake him up when I brought in the snack" so I couldn't get a clear answer. But the more I think of it, the more I think he might have urinated in the cup - but I can't figure out how he could do that, get the lid back on and put it back without spilling it! But he does have the dexterity to empty his colostomy bag (with supervision) so maybe he did? I am just feeling so sick to my stomach right now I don't know what to do!
    I'm sorry to laugh, but that cracked me up. The poor guy!
  3. by   SammyBSN
    I almost gave IM thorazine IV... didn't realize it until the pt. "assumed the position" for his IM shot... and there I was with the blunt/needless system... worst of all, the charge nurse was right there watching. I said "Err... oops, I have the wrong type of needle, be right back." But yes, the slow sinking feeling of what I almost did hit me.
  4. by   Mulan
    Quote from Pepper The Cat
    OK - I really need to tell someone this. I am feeling sooo sick right now.
    I think I gave my pt a drink of urine. yes, urine! All day, I've been caring for a pt who is confused, periods of aggression, etc etc. he likes to drink a lot of ice water, so I made sure all day that I had fresh ice water on hand - not easy because he is also in isolation. Just before I left today, I went to check on him, he was a little restless and wanted something to drink. So I grapped the cup of water I put there at supper. He took a sip (a very small sip!) and said 'that tastes funny" - I opened the cup and looked in, it was a yellow fluid. I thought maybe another nurse brought in apple juice when she brought in his HS snack (even though I told her not to disturb him and it was too early to bring in an hs snack) but as I dumped it (because he didn't like the taste) the smell hit me. It smelled like, well, pee-pee. The other nurse denies bringing in apple juice, but then kept diveting to how "I didn't wake him up when I brought in the snack" so I couldn't get a clear answer. But the more I think of it, the more I think he might have urinated in the cup - but I can't figure out how he could do that, get the lid back on and put it back without spilling it! But he does have the dexterity to empty his colostomy bag (with supervision) so maybe he did? I am just feeling so sick to my stomach right now I don't know what to do!
    Do you also write for MAD magazine?
  5. by   mandykal
    OMG!!! I remember this post when I was a student in 2004. I now can add my first med error.

    My first job was 11-7 shift, and part of my job is to follow-up with suppositories. Well, this one pt, it was dark in her room and when I inserted the suppository, I missed the anus and entered the you know what..... Now you can bet that my lights are on regardless....
  6. by   *DNR*
    i was a nursing student working toward my lpn at the time, and was doing flu vaccinations at a dr.'s clinic. i must have done at least fifty shots in one day, with no apparent problems. within a couple of days one of the nursing instructors pulled me aside and asked if i knew the proper prodedure to giving im shots in the deltoid. i gave the right answers but she told me one of the patients had bursitis because i gave the shot too high in the deltoid. while doing clinicals one of the nurses told me if i gave the shot higher, it would hurt less. no repercussions occured, luckily, and the pt was treated with steriods (at no cost to them). i felt horrible, but realize now to trust what you learn in class.
  7. by   gr8rnpjt
    Quote from danissa
    :imbar !! I felt that My worst mistake to date, was not with a patient but with my dd Hollie! I was 18 yrs old when she was born and not a midwife at that time.Around 4mths old she had an ear infection, doc gave me Amoxil--WITH Syrynges!! Remember guys, 18, NO previous baby experience-- What to do?? (NEVER HAD SEEN SYRYNGES PO!) So, I gave the meds in her EAR, only when my Mum noticed the bright yellow sticky goo, (after a good few admins!) and screamed out, she thought the infection was ooozing!! BUT it was the amoxil running out ! OMG!! So mortified!! By the way this fab girlie is now 19 yrs herself and has PERFECT hearing!!! I know its not as scary as some of the other guys experiences, but I felt like the worst mammy in the world at that time. I ALWAYS stress to parents the right route etc, for drug admin, & never take for granted that they will know:trout: !

    This cracked me up for some reason. Imagining your poor baby with all that sticky pink stuff pouring out of her ears. Seriously, you were probably mortified, and at 18 I probably would not have known better either. Glad she turned out ok and her hearing is fine.
  8. by   grace90
    -titrated a heparin drip 100 units too high, lpn caught it, i reported it to doc who did not chew my head off thankfully, pt was ok
    -gave the wrong meds several times in LTC as a new lpn- major reason i will never work LTC again (no offense to you special nurses who do, kudos to you)
    -gave a demented ARf/dehydration decreased LOC lol 1 mg of dilaudid, which was ordered as a 1x dose, and an hour later she coded and died, still sorting that one out and it still haunts me that i didn't catch that something was wrong sooner
    -picked up a pill off the floor that i dropped and gave it to a pt, stupid as h#$% why i did that, i know i was stressed and tired, but geesh, i still beat myself up for that one, dumb dumb
    -gave a tyl 3 instead of a vic to a pt, not allergic, this happened at 2 am and i called his ortho surgeon at 7 and he said "thank you for not waking me up at 2 am to tell me that"
    -gave 1 mg of dilaudid to a post-op instead of 0.5 mg, pt wasn't harmed, doc actually ordered the med to be 1 mg the next day, handed incident report to nursing supervisor and told him i screwed up, he asked "did ya kill anybody?", no, "well, ok then"
    -was supposed to turn down iv to 75 from 125 after x amount of hours, forgot to until about 4-5 hours later, this was last night

    this is just what comes to mind right now, there are many more i'm sure... what scares me is that i probably made errors i didn't realize, eek!

    i never carry narcs that i retrieved from the med room lock-up into another pt's room than the one it's intended for, and this has caused me to get yelled at a few times (i need you to help me draw this pt, no i got a narc in my hand, you gotta wait!)
  9. by   Magsulfate
    Quote from jhowirn
    Once upon a time, in the icu, I was taking care of a patient who was receiving iv fluids and Diprivan. Sometime, during the night, I went in to hang a dose of iv antibiotic, which I piggybacked into the iv fluids. I dialed the amount and rate of the antibiotic, pushed the start button, and left the room. About 10 minutes later, I looked up at the monitor which informed me that the arterial line bp reading was like, in the 70's/30's. Not good. I ran into the room assessed my patient and the situation. The source of the low bp quickly revealed itself. I had dialed the rate of administration for the antibiotic into the channel that was running the Diprivan!!!! I wanted to vomit, I was so horrified at what I had done. Fortunately, the problem was easily reversed by turning off the Diprivan, and within 30 minutes, the patient's bp was fine. Lesson learned: to this day I don't run Diprivan and fluids on the same pump!
    I know this post is a few years old, but I have made a mistake ONCE with diprivan (propofol) aka milk of amnesia.....

    This patient was vented and on diprivan. A very small lady. SHe was very active, even while on diprivan. It took A WHOLE LOT to knock her out. Anyway, I was changing the dose, increasing it a little and ended up adding an extra digit to the rate without realizing it. Luckily, I decided to stay in the room and clean up. I remember thinking to myself *wow, she sure is sleeping really good now* Took her b/p and it was in the 70's. I was like *holycrap* I felt myself melting to the floor. I turned off the drip fast like, and almost a minute later she was waking back up and being her own self again. Thank goodness diprivan has a fast half life. After that I always triple check my dosages on the pumps. For a few weeks, even on my breaks, I would call back up to the unit and ask my covering nurse to go in the room and recheck my drips.
  10. by   youngever
    I am in my first year of nursing on med-surg. Last night, I piggybagged heparin drip with NS for pt with DVT. I did not know that I was not supposed to piggybag heparin. I came home this morning, my manager called me that pt did not receive his heparin and ended having central line caused by my mistake. HR is investigating about my mistake and for now i am suspended until the investigtion is over. I know this is a serious mistake. could I get fired from this? I thought that I was getting better and this is very frustrating. thank you for reading. I would appreciate for any thought.
    Last edit by youngever on Jul 27, '07
  11. by   bakpakr
    I know this is an old thread. I'm not in school yet but it is on my mind all the time. I am excited and also very apprehensive. And reading these just scares the bejeezus out of me. I know that i am going to make mistakes as they are a part of learning. All my life I have been the first to own up to my mistakes and will do so in my nursing career but mistakes in nursing have far worse consequences than any I have ever made as a mechanic and that is what scares me. Just thinking that i may make a mistake that either ends someones life or does irreparable harm just scares me to death.
  12. by   military girl
    Hey,
    Don't be too hard on yourself. I know how you feel. My first 6 months out of school, I gave a dose of Vanc to a renal patient that was too high. I did not know the correct doseage for a renal patient, and the patient had come up from the ER, and two doctors had looked at the order and determined that it was correct.
    The next morning the pharmacist came in and asked if the patient had received the doseage and if he did, it was not a good thing. We had to give him IV fluids and check his labs until he was okay. To this day, this is the reason why I will not work in a small community hospital where pharmacy is not there 24 hours.
    Mistakes will happen. We have to learn from them. I have been a RN for 6 years now, and last year I was deployed to Iraq, so there is always an opportunity to learn.
    Take a breather and start again.
  13. by   BreezieRN
    It seemed like this happened in slow motion for me. We let our outpt psych pts go outside for a few mins when I saw my elderly gentleman roll his wheelchair off the cement and into the grass. I tried so hard to get to him before he tumbled over and landed right on his head!!! He had a few scratches, no change in LOC. I filled out an incident report and he turned out just fine. My heart still races as I remember him slowly turn over..............

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