Your worst mistake - page 29

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   alkaleidi
    I don't have a "worst" mistake, mine are all just stupid, but I *will* tell on a friend who made a bad (somewhat hilarious looking back) mistake...

    We were working med/surg and of all times, at like 3am she got an order to change the foley on a nursing home pt who came in. The guy was probably in his 90's, unresponsive, and the foley looked like it had mussels or barnacles on it -- crusted, the tubing in the penis was disgusting, it was just... BAD.

    So she goes to remove it and I was bored, keeping her company, and for who knows WHAT reason when she took her little 10CC syringe in to deflate the balloon, she pulled back the plunger, hooked it up to the foley, and proceeded to shove 10CC more INTO the balloon.

    Why, I have no idea, but I was in such shock that I busted out laughing HYSTERICALLY. I think mostly because I was relieved that it was her that did it and not I. Either way, obviously it was a rather large mistake especially since the balloon popped and the foley slid right out... LUCKILY the balloon was VERY much intact with the exception of where it had broken. In her defense, the cath really looked like it was rotten, and probably didn't take much to burst that balloon.

    So yeah... to this day I remind her of that. LOL. I know, I know, it's terrible to laugh at something so stupid and such a simple thing that should not be mistaken... but, people make mistakes. Learn to forgive yourself now so when you have that "Oh Sh!t" moment later, you don't beat yourself up so much.
  2. by   RNsRWe
    Oh, man, I hope there's no lawyers trolling this thread! Please, be careful what you post, folks!
  3. by   trimm
    I wish I could cry. I have had hot flashes, heart palpitations, anxiety through the roof over errors I have made. I know I am in the wrong profession because my OCD is killing me. I am a male nurse and that doesn't keep me from crying, but I would love to just break down once and get this off my chest.

    I lost a job over med errors.

    I worked the evening shift and every other weekend I would have to work days. Can you see where this is going? I was passing am meds and on one pt got it in my head that it was evening and pulled the wrong tray of meds. I even checked them against the medex as if it were evening. I didn't hear about it till the evening nurse called me and told me I passed the wrong meds. There was no harm done and we both survived it.

    About 6 months later I did the exact same thing. Got put on probation and could have 0 med errors in 6 months. I made it 3 months before I forgot a pill on one lady. Once again, on day shift.

    My next job I was so focused on the med cart that my DON told me that I spent too much time on it. She was right, I was never going to do that again yet she criticized me for it. I never volunteered to work a different shift than my own so I would not be able to make the same mistake.

    I did make another mistake with an eye drop later though. It was atropine for a Hospice pt and was to be given orally. I guess it didn't make sense why you would give an eye drop in some one's mouth, and looking back, it was labeled po. I guess I thought it was an error and didn't check.

    It is sooooooo easy to make a mistake as a nurse when you have 35 pts. and no med aid and 2 CNA's. The sinking feelings I have read about on this post is so common, the fear, the dread, the over compensation to make sure you make no mistakes.

    It is sad that we all work so hard just to get that license, and then are almost set up to fail in some circumstances. I would like to get out of nursing so I can live a normal life and not worry about the feeling of dread I get when I make a mistake.

    I make mistakes. The world needs to get over it.
  4. by   emmalou*
    Quote from trimm
    It is sad that we all work so hard just to get that license, and then are almost set up to fail in some circumstances. I would like to get out of nursing so I can live a normal life and not worry about the feeling of dread I get when I make a mistake.

    I make mistakes. The world needs to get over it.
    I really felt for you reading that. It's very difficult to do your job well, particularly a task like administering medications, when you're anxious or stressed out with too high a workload. Anxiety is crippling. Even with day to day activities, much less work tasks.

    Nursing isn't for everybody. Hell, nursing is probably not for most people - most of us muddle through the day, doing our best, hoping we don't make an error - that didn't stop me going home at night, lying awake worrying I'd given the wrong dose, had forgotten something or had offended a patient somehow.

    I agree it's an occupation which sets people up for failure - if you're not 100% on the ball, confident, knowledgeable and skilled all the time, you run the risk of making errors - and really, who can say they're all that and a bag of chips every single day?

    You have learned many skills from nursing - use that to move into another area and be happy. In my current field, I see many unhappy people who hate their jobs, everyone has the right to like what they do most of the time.

    :heartbeat
  5. by   nicetomeetyou
    I'm a new grad have been working for a few months now, but I made a really idiotic mistake. I was giving an SVN treatment, and the o2 was running at 6L. I stayed with thr patient throughout the treatment, and after it finished I started talking to her and turning the nob down on the o2. Or so I thought. I start hearing this hissing noise, then all of a sudden I hear a huge POP! as the oxygen tubing pops off the mouthpiece. It nearly gave me a heart attack. Luckily the patient did not get hurt, and we had a good laugh after I told her what happened. But man oh man I still kick myself at not looking at the o2 gauge first. ugh.
  6. by   gwafuh_rn
    I want to share another story that happened to me a while ago.My supervisor called me and told me that the patient that I handled last week died and she told me that she is gonna write me up.I worked day shift and the patient died that night.The patient's bp during my shift was kinda low.It was 90s/40s.There was an order to give lasix q 3 days.I hold the lasix because of the bp.I forgot to tell to my supervisor that the bp was kind of low.But I called the cardio consult of the pt and told him about my concerns.The dr told me that the bp is ok and to hold the lasix if the systolic is less than 100.During endorsement,I told the night nurse that the bp was kinda low so I need to hold the lasix.He told me that the pts bp was okay.The patient died that night.The primary doctor got upset because if she's the 1st one to be informed,she'll order a bolus of ns right away.I was really frustrated because that day,the family was thanking me for the care that I did to the patient.Anyways,my supervisor asked me why I didnt call the primary?Why do I need to call the cardio consult.I was speechless that time.
  7. by   wanderinrn
    I have made a few med errors in the course of 16 yrs of nursing...but one of the things I did that bothered me most was one morning, on a busy med-surg floor, rushing trying to stay 'on top of things'....had 6 or 7 pts and was primary care, no nurse aides to help with pts needing feeding, etc. Dietary had brought in the tray for this particular pt and set it on the bedside table, but that was all they do. I had gone in and opened the milk, put the straw in, etc, silverware, etc. Spoke to the pt, then rushed on to the next. When I stepped in again to the room OT or PT or some tech was there, and I learned the pt was in restraints and with the tray right there, smelling the food, but unable to get to it. The pt, best I remember, was confused, anyway, the tech was saying 'I really should write this up'....They were not very nice about it, but I can understand why. But, the thing is, it was very early in my nsg career, and I felt like I was sinking anyway. This just made me feel so bad. As bad as any med error. I never heard anything more about it. But, I sure beat myself up on it so much. I don't remember if I had gotten in report that the pt was confused and was a total feed. It's been too long, but I would think I probably did, and just got in such a rush that I forgot and with the pt being covered, I just assumed she wasn't ready to eat yet, and went right on to the next thing.....But, in the end, it wasn't a life threatening problem and no long term effects...
  8. by   robby5313
    My first mistake: 2 kids come into the pediatrics office for allergy injections. Same first name, last name with the first 2 letters the same. Yep....I gave the wrong serum to the wrong patient. I was in tears. Stomach drops...I go to the Dr. crying. He calms me down, reassures me that it is fine and it was...turns out they were on almost exactly the same serum....you can believe i double, quadruple check now!

    second mistake: working in a LTC facility. All the Coumadins were given at 4 p.m. there was a change in this order for Only one patient (my patient) got his Coumadin at 12 noon. So I give it at noon. Well the nurse that re-ordered the new order and re-ordered it at 1600. So what do I do? Didnt check the MAR and gave it at 1600 also. You can bet I check the MAR now!
  9. by   Jay2daq
    I once was to administer "Rogaine"...yes Rogaine! I was really confused because i knew Rogaine was used for hair growth. instead of looking it up, i gave the patient her Rogaine, without looking at her blood pressure! (which i was 86/40). Gave her a couple of her other medications. Nothing serious came of it, had to give her a bolus. but i did learn from this to look up ALL medications if its one im not used to giving. I think on our units we get so used to certain medications and when we see a new one we just can sometimes go ahead and give it....
    Now that i look back on it, What was i thinking?? Hair growth medication in the hospital?!?!? REALLY JAYDA? ...

    F.Y.I. Rogaine is used to lower BP. Its side effects is hair growth (thats where they got rogaine)

    We learn from our mistakes and just hope and pray its not a serious one!! Thanks for everyone sharing their stories.
  10. by   Nurse4life09
    I shutter thinking about this, but have since learned from my mistake. As a new grad with only a few month's experience, I was working on a neuro/neurosurg floor. I cannot remember what disease my patient had, but something neuro. The R1 was doing something spinal, and asked me to give the patient 2mg Ativan and 25mcg Fent routinely over a period of about 2-4 hours (I cannot remember). So over the course of that time frame, I gave the patient about 8mg Ativan IV and who knows how much fent, 100mcg? 200? I really had no idea. Turns out, I was performing conscious sedation for a patient with an R1 on the floor. But I thought it was ok because I was with a "doctor". The doctor must've thought it was OK because they must perform this with RNs (in the procedure room) Finally towards the end of the shift, I think I finally told someone that I thought it was wrong, but it was too late, though the pt was still alive, the night nurse just had to check vitals every 30 min. The patient was pretty much "hungover" all night and all the next day. I was so embarrassed during report the next morning. One of the nurses said really loud, who in the heck would give a patient that much medication? and everyone laughed. No one knew it was me, except for my charge nurse. I had a chat with her later that day, and I think I got written up, but she also said that I didn't know because the R1 asked me to do so. I still don't know how I could've taken that much meds out of the Pyxxis, but it allowed me to, I guess by having a witness to waste the med?

    It's been a while since this has happened, and I have learned to always ask another nurse if you are unsure, to brush up on what can be done on said floor, especially if you need to question the doctor, resident or not.

    Also, a patient was allergic to oxycontin, and I gave the patient oxycodone. I dont know what I was thinking, I reported it to the doc, and he just laughed and said, wow, I should've checked that myself. Nothing happened. The patient was cool about it. Turns out, the allergy was "n/v"....hate that!!!
  11. by   syckRN
    I had been a nurse for about a year. I had two chest pain patients in the ED and both were so unstable that I was literally standing between their stretchers so I could watch them both. Both of their blood pressures fell due to the Nitroglycerin infusions and I had them BOTH in trendelenberg. One of them kept saying, "Something is wrong." I know that when patient says this...they are usually headed for the drain.

    Turns out, another nurse who had come in to "help" me had supposedly started a NS bolus on the patient. Unfortunately, the Nitro gtt was piggybacked into that line...the patient got an entire bottle of Nitro in 15 minutes!!

    The half life of Nitro is about 7 seconds. The patient lived.

    I however wanted to die!

    That was 14 years ago. You can bet your sweet ?*& I never made that mistake again.

    SyckRN
  12. by   Morainey
    I know this is an old thread but...

    My worst mistake so far has been putting the wrong ID band on a patient with dementia, but who could say her name and birthday.

    SUCH a dumb mistake, I even made sure it wasn't too tight that it cut off her circulation but not so loose she could pull it off, and took out my nursey scissors and snipped off the excess so it wouldn't be flopping around in her dinner tray. All without ever LOOKING at the ID band.

    Didn't get discovered til evening shift though (I work 7p to 7a) - what's the deal with that :uhoh21:

    Now you better believe I check that ID band the first time I walk in the room, and any time I medicate that patient!

    Before that, I was beating myself up about infiltrating an IV (not massively, but it sure seemed that way). Just NS, and the swelling went down pretty quickly, but I felt awful about it.
  13. by   MomRN0913
    Quote from Magsulfate
    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.
    Oh bejesus, I did the same thing! I thought I was the only one.... 15 mintues passed and i noticed a hr drop. I shut it off and he woke up loud and clear in like 5 minutes!!! I almost passed out.

    My coworker did that with a cardizem drip......

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