Your worst mistake - page 30

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   Nebby Nurse
    Some years ago when I worked in the nursing home industry I cared for an obese tube feed grandma with advanced dementia. The tube was out and I grabbed a new one to replace it. Couldn't insert and thought :This thing has probably been out for hours... So I decided to spare the poor resident the disruption of a trip to the ER. I started poking the opening with a wooden swab. Grandma is looking at me and saying "ah argh ah". After a few minutes of poking I assess the situation and realize I am poking her'inny' belly button with my wooden weapon. One of many idiotic mistakes.
  2. by   Trekfan
    This is not nursing one but it was a big one ! I used to Handel some stuff for the mill.and gov. That also meant I dealt with embassies one day I got a call from JFK about some paper that was not right and this shipment was for an embassy ( they have there own planes ) so I had the plane and "crew" held well I handed the paperwork off to the right people but later got busy and FORGOT I had the plane and crew of hold !!!!!
  3. by   Jenni811
    as a newer nurse, i can say i have made mistakes...they have been very minor thankgod!!! But i've learned from them.

    All i can say is, trust your instinct with giving a medication. When something just doesn't seem right, you can always ask the doctor. i would say 90% of the time i am correct, because phyisicians ARE people too. They can make mistakes just as easily as nurses. I once had a doctor order Potassium IV for a patient who was in fluid overload and was taking oral supplements just fine. I called the doctor to let him know that if i give the potassium IV that would be a 500cc bag, which is the same size bag as our bolus, and the patient is taking oral just fine. Doctor thanked me and discontinued IV order and reordered for oral potassium
    Or another Example:

    "Mr. Jones is going in for a heart cath this morning. Do you really want me to still give that lovenox?"

    Usually they appreciate your call. Even if you are wrong and that is the order they DO want, they rarley ever get upset for questioning that order. Cause if you question it, it is usually for a good reason.

    I once still did not feel comfortable giving the medication the doctor ordered (a WAY WAY high dose of opiates who was already given a very high dose and pretty much knocked out, respirations ok but still...). After doctor still said "yes that is what i want" i actually consulted with the pharmacist on our floor and had him talk with the doctor. The pharmacist agreed with me on this one. The doctor was upset with me, but honestly....i know where the patient is at this point. The doctor didn't see the patient before ordering the med.
  4. by   FlyingScot
    Guys, as helpful and interesting as this thread is I think you might want to think a bit before admitting these kind of mistakes for EVERYONE in the world to see. These forums give the illusion of anonymity and there is still the possibility that someone could figure out who you are.
  5. by   whichone'spink
    I gave Plavix to a patient who was thinking about having a lap chole but it wasn't a done deal yet. Shortly after I gave her medications, the doctor came in and she said she wanted to go ahead with the lap chole. She needed FFP and platelets. The primary nurse told me the next day, and somehow my instructor did not find out. I will not do that again, that is for sure. Better to make mistakes as a student than as a licensed practitioner.
  6. by   Nurse3000
    my goodness glad you came out the other side.. im sure you havent made a mistake like that again!
  7. by   Nurse3000
    Quote from Tweety
    Yikes. What a nightmare indeed. Question, why did the assistant nurse manager loose his/her license?
    absolutely horrible. wouldnt wish on worst enemy fate of those poor nurses and the poor pt. shocking
  8. by   Nurse3000
    thats nice of you nurseie 30 to keep on supporting, more nurses like you pls.
    Quote from Nursie30
    Boy, admitting is hard, but we know we have to do that, forgiving ourselves is almost impossible.
    I was fresh out of LPN school, working evening shift by myself, pt chokes in dining room, I called out for a code status, the SSD went and checked the chart, running back in and yelling, "She's a Full Code" so I began CPR, the pt was revived, the EMT's arrived, and about 30 minutes later the hospital calls, and notifies us that the pt was a DNR on their records. I went to check her chart, and although there was no yellow flag in front of chart, or a sticker, or even an order on the current MAR, looking back about a year, there it was, the Doctor had wrote an order for her to be DNR d/t terminal illness, it was never pulled forward. She was in the hospital for about a wk, and I was so worried about the state that she would be in when she came back, but she came back as the same old fiesty lady, which made me feel better. But just imagine, the adrenaline of the code, excited about actually doing a code successfully, people patting me on the back, feeling 10 ft tall, and then the call saying that she was a DNR.
    So....my big ole soap box wherever I work is asking what the status is, asking what the family wants if they've changed their mind with decline in conditions, and making the SSD aware, nurses, CNA's, whoever what a pt's code status is.....it was a horrifying experience....

    On the lighter side, I have inserted a foley in the wrong "umm" area, and reported no output at end of shift, to have dayshift find out, I wasn't a very good mark.

    And we all know how scary it is when you realize that you have given the wrong meds to the wrong pt, fearing the worse, not wanting to call the doctor, and kicking yourself the whole time knowing that is was just plain dumb, or rushing or whatever.......
    To the RN that quit because of the Insulin? You really need to get over this, 50 Units was a tad bit too high, but we all make mistakes, don't give up something you love......that is so sad......you are probably a very competant nurse, obviously caring if it has affected you this much, go back to doing what you love.....
  9. by   RNator
    Getting married
  10. by   NickiLaughs
    Worked in critical care and this genius doc decides to stop the levophed on a pt "to see what would happen. " instead of just pausing it. He took it off the pump and threw it in the trash. I have no idea what made him think that was a good idea...
    I run to mix another get because his pressure was tanking fast. The pt was almost maxed out on levo...I was so mad because if he didn't need it he would have been titrated off!
    I get in the physics and pull two vials of levo because the concentration was 8 mg and grab my 250 bag. I grab a nurse for my double check. She gives the nod. I look at the vials one last time and realize it's a neuromuscular blockade. ...it had been loaded in the pyxis under the wrong section.
    I break out in cold sweat. I go and grab the right vials from another pyxis and mix the med for the pt. Get his BP out of the 60s....
    Call pharmacy. ..send they're there the fastest I've ever seen them fixing the meds to the correct pyxis.
    I was so grateful I slowed down and finally look at what I'm doing. He was not tubed and probably would have coded because of me not reading the vial and just assuming the right med was known the pyxis.

    Another time I took over an assignment and this pts BP was in the 70s a day had been all night from the trends. The night nurse was still charting and I checked my levo all the way up. ....it was azithro that was hanging. I informed her and she tried to bully me into not reporting. But the error would have fell on me had I not.
    I felt bad because her and another nurse got written up for it among other things. It had been hanging for over 24 hours per the MAR.
    That's when I realized the facility I worked for wasn't interested in being safe, they were interested in writing up staff and assuming human error wasn't expected. I still have PTSD from that hospital.
  11. by   Longleggedstar
    I know this is old but that's a good one, I was scared for you just reading it!
  12. by   srercg6
    I didn't read all the pages of comments, so I'm sure someone else already asked about this - but, doesn't blood have to be in within 4 hours? I wish I worked with understanding people - they were only understanding while I was working with a "popular" preceptor - after that - every mistake I made or anytime I asked for help I was made to feel stupid - in fact one experienced nurse who is assigned to walk the floor and help other nurses actually calls nurses stupid idiots all the time - usually waits until she's with other nurses and that nurse isn't around -but if she doesn't to one nurse in front of me - I'm gonna assume she's doing it to me in front of them....
  13. by   Davey Do
    Quote from RNator
    Getting married
    Twice.

    Third time's a charm.

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