Your Worst Mistake

[aurora_borealis]

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, because there is no excuse for a hospitalized patient to suffer DT's if someone knows what they're doing, but I digress.)

Anyway, back to this unfortunate soul.

Because he was delusional and combative, he was restrained so he couldn't yank his IV out for the 10th time. They had also wrapped his IV site with kerlex as an added precaution...maybe if he couldn't find it he'd leave it alone. He was also being transfused with a couple of units of blood.

When I got there, he was nearly through the first unit, and I was to finish that and hang the next one. Well and good. Or so I thought. I started the second unit, but I had one hell of a time infusing it. I literally forced it in with the help of a pressure bag, and I am not kidding when I say it took a good 6 hours to get that blood in. Meanwhile, the patient was getting more and more agitated, which I attributed to his withdrawal.

Finally, mercifully, the blood was in so I opened up the saline to flush the line. But it wouldn't run. All of a sudden I realized, with absolute horror, what had happened.

I cut off the kerlex covering the IV site hoping against hope I was wrong, but alas, I wasn't. Yes indeed, I had infiltrated a unit of blood. I hadn't even bothered to check the site.

No wonder he was so agitated, it probably hurt like hell.

An hour later my manager showed up, and I told her what happened. She was probably the most easy going person I've ever known, and she told me not to worry about it.

I said "Listen to me, I infused an entire unit into his arm, go look at it." She did, and came out and told me to go home. I expected consequences, but never heard another word about it. But I am here to tell you I learned from that mistake.

[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.

[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.

[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..............

[treysdaddy08]

This happened 15 years ago and it has haunted me so much, I left bedside nursing and went into other areas (utilization review, case mgmnt. etc)

I had been a nurse only 2 years and had been working in med-surg/stroke unit. I was off duty, at a birthday party. Most of the guests were in their early twenties and there was drinking going on. The host (the brother of my fiance) had an unwitnessed fall down a flight of stairs. My fiance found him and called for me. I took charge of the situation, instructing others to call 911, checking airway/breathing/circulation etc. I suspected he had a broken neck, but he had a faint pulse and was breathing. So, kneeling at his head, I stabilized his head/neck between my knees and lifted his jaw with my fingers to keep his airway open (jaw thrust maneuver) and kept re-assessing him, waiting for the EMTs to arrive. Well, to his family, it didn't look like I was "helping" him enough. I had hysterical family and friends in various stages of drunkeness (I had had less than one drink) and then, the worst happened....one of his brothers, crying that I wasn't doing anything (with others agreeing), pushed me out of the way and tilted the victim's head back (hand on victim's forehead, other hand on victims jaw) to listen for breath sounds/initiate CPR. I can still hear the bones in his neck crack when I remember that.

Of course, then he became pulseless and breathless and needed CPR. So, to the family, I wasn't doing anything. Luckily, the EMTs arrived right after that but he was DOA when he arrived at the hospital.

I still carry a lot of guilt about that situation; the "if only" syndrome....

It crushed my self confidence and my belief in my skills.

Someone died and I could've/should've prevented it.

Unfortunately, there's no rectifying this situation. There's no remedy, no counter-action to take. A young man is dead and only I know all the details of what happened. I pray for forgiveness daily.

I hope that by sharing this, others will

1) be cautious at all times, both on and off duty. You may be called upon to help in emergency situations

and

2) if you decide to take charge of a situation, be assertive/aggressive and don't let non-medical bystanders interfere (by imitating what they've seen on TV)

I understand you guilt, but honestly I can't see where you went wrong. YOu were providing proper care, and if you were literally pushed aside then there was nothing you could do about it. You knew that they shouldn't do what they were about, you did what should have been done, and they interviened. You did all you could, I'm sure. Don't doubt your skills...doubt your gene pool!!

[doe9181]

This happened 15 years ago and it has haunted me so much, I left bedside nursing and went into other areas (utilization review, case mgmnt. etc)

I had been a nurse only 2 years and had been working in med-surg/stroke unit. I was off duty, at a birthday party. Most of the guests were in their early twenties and there was drinking going on. The host (the brother of my fiance) had an unwitnessed fall down a flight of stairs. My fiance found him and called for me. I took charge of the situation, instructing others to call 911, checking airway/breathing/circulation etc. I suspected he had a broken neck, but he had a faint pulse and was breathing. So, kneeling at his head, I stabilized his head/neck between my knees and lifted his jaw with my fingers to keep his airway open (jaw thrust maneuver) and kept re-assessing him, waiting for the EMTs to arrive. Well, to his family, it didn't look like I was "helping" him enough. I had hysterical family and friends in various stages of drunkeness (I had had less than one drink) and then, the worst happened....one of his brothers, crying that I wasn't doing anything (with others agreeing), pushed me out of the way and tilted the victim's head back (hand on victim's forehead, other hand on victims jaw) to listen for breath sounds/initiate CPR. I can still hear the bones in his neck crack when I remember that.

Of course, then he became pulseless and breathless and needed CPR. So, to the family, I wasn't doing anything. Luckily, the EMTs arrived right after that but he was DOA when he arrived at the hospital.

I still carry a lot of guilt about that situation; the "if only" syndrome....

It crushed my self confidence and my belief in my skills.

Someone died and I could've/should've prevented it.

Unfortunately, there's no rectifying this situation. There's no remedy, no counter-action to take. A young man is dead and only I know all the details of what happened. I pray for forgiveness daily.

I hope that by sharing this, others will

1) be cautious at all times, both on and off duty. You may be called upon to help in emergency situations

and

2) if you decide to take charge of a situation, be assertive/aggressive and don't let non-medical bystanders interfere (by imitating what they've seen on TV)

I'm So sorry for your pain. This is not only your fault. I feel that it is the brother's fault for not listening to a health care professional. I understand that he was hysterical but he ultimately made the mistake, not you.

My mistake occured my first week as a nurse. My preceptor told me to bolus a patient with 1 liter normal saline so I did. He was going to the OR. My preceptor asked if I did the order and I said yes, one liter bolus. She was like "no I said put him on KVO (keep vein open) at 10cc/hr. Mind you the patient was adouble lung transplant patient who was easily overloeaded. We both freaked out but luckily the patient was ok. I still swear to this day that she told to bolus one liter. Where else would I have come up with it?

[Becca608]

If you have to force something in or out, it isn't right

[Zookeeper3]

DAMN, there are some serious ones that have torn into nurse souls. A pitty, patients don't know how we suffer in silence because of them.... even when they sue. If only they knew our sleepless nights.... We should start a log journal and book, only to be violated by lawyers to sue later....;)We'd keep it to ourselves and be cathartic, healing... anyone want to start?

lets turn this positive!

[EmmaG, RN]

We should start a log journal and book, only to be violated by lawyers to sue later....

I worry about threads like this; after all, it is a 'public forum'. Providing too much information about "your worst mistake" might end up being "your worst mistake".

[Julie029]

I am sooooo glad I logged on today. I have been a nurse on a med-surg floor for only 9 months. I had worked with heparin drips very little. Recently at the end of my shift a Dr. ordred a heparin drip on a patient. I had just started to give report to the nurse for the next shift. I told her that I would stay and hang the heparin for her. After finishing report I got the bag of heparin and went to the patients room. The nurse taking over went with me. The pump was to be set for 4 cc per hour and I set it for 40. However I did not press start yet. I turned to the nurse and asked if that was correct because I had not worked with heparin drips much. She went balistic. Became very verble. And then has been telling everyone what a dangerous nurse I am and that she doesn't want to take report from me anymore. I am still wondering if I should be a nurse now. I would not have started that pump without asking someone to check it for me. Shouldn't that count for something? Anyway as I have read your posts today I feel much better. Thank you for sharing.

[scattycarrot, BSN, RN]

I am sooooo glad I logged on today. I have been a nurse on a med-surg floor for only 9 months. I had worked with heparin drips very little. Recently at the end of my shift a Dr. ordred a heparin drip on a patient. I had just started to give report to the nurse for the next shift. I told her that I would stay and hang the heparin for her. After finishing report I got the bag of heparin and went to the patients room. The nurse taking over went with me. The pump was to be set for 4 cc per hour and I set it for 40. However I did not press start yet. I turned to the nurse and asked if that was correct because I had not worked with heparin drips much. She went balistic. Became very verble. And then has been telling everyone what a dangerous nurse I am and that she doesn't want to take report from me anymore. I am still wondering if I should be a nurse now. I would not have started that pump without asking someone to check it for me. Shouldn't that count for something? Anyway as I have read your posts today I feel much better. Thank you for sharing.

Of course you should still be a nurse! You didn't do anything wrong! You knew you weren't sure about the infusion rate and so you didn't start it but double checked with a supposdly more experienced nurse and asked for her advice. You listened to your inner voice and prevented a medical error from happening. I am disgusted at that other nurses behaviour and I almost think that you should talk to a superior about her reaction which was out of line and not helpful at all. VERY unprofessional and its a form of bullying which should not be tolerated by you or anyone else. You need to learn to stand up for yourself, which is much easier said than done. This makes me so cross as its attitudes like this that make people reluctant to own up to their mistakes and if you have leart anything from this thread its that you must always admit that you don't know and admit when you have made an error. I will ask you though, did you have the written drug order with you when you went to set the drip up as it should have had the infusion rate on there or at least the titration parameters? Don't start anything without a written order. You will see more experienced nurses doing this but at your stage in your career always have written orders. Anyway, you did fine and asked when unsure, you knew to double check and you will be a fine nurse. Just don't let the nurses unprofessionalism get to you. Good luck.

[HipsterNurse]

i have been working as a nurse for 2 months...

#1: I gave a kid with a g-tube a med by mouth and was not supposed to. the order said po. the mom wasnt in the room, but she walked in after i gave the meds and the baby was coughing. she started yelling at me "didnt the other nurse tell you to put the meds in the tube!?" i traded patients with another nurse.

#2: I had a MRCP kid with a trach and a mist collar. When I was changing her diaper her trach fell out and she turned blue and desat to 50% i thought maybe she was having a lot of secretions in her trach because she had been all day but not to 50%. another nurse came in the room and put her trach back in in a rush thank god. we had to call rt to put another trach in and assess her. we had to put the % on the mc up to 35% instead of the 28% that it was on before. her sats went back up into the 90s eventually after multiple deep suctioning and trach replacement. i was supposed to wean her to room air that day. think i did it? nope. i felt horrible. the nurse asked me why i didnt call someone sooner and said that i seemed oblivious to what was going on.

i have been learning some hard lessons in these first 2 months of nursing =(

[kristenncrn]

i have been working as a nurse for 2 months...

#1: I gave a kid with a g-tube a med by mouth and was not supposed to. the order said po. the mom wasnt in the room, but she walked in after i gave the meds and the baby was coughing. she started yelling at me "didnt the other nurse tell you to put the meds in the tube!?" i traded patients with another nurse.

#2: I had a MRCP kid with a trach and a mist collar. When I was changing her diaper her trach fell out and she turned blue and desat to 50% i thought maybe she was having a lot of secretions in her trach because she had been all day but not to 50%. another nurse came in the room and put her trach back in in a rush thank god. we had to call rt to put another trach in and assess her. we had to put the % on the mc up to 35% instead of the 28% that it was on before. her sats went back up into the 90s eventually after multiple deep suctioning and trach replacement. i was supposed to wean her to room air that day. think i did it? nope. i felt horrible. the nurse asked me why i didnt call someone sooner and said that i seemed oblivious to what was going on.

i have been learning some hard lessons in these first 2 months of nursing =(

^^ Geesh. Chronic kids are tough for most people until a whole lotta experience. Tubes in tiny bodies - it's a bit overwhelming. And I have NEVER had a trach fall out (yet). We do the best we can and learn from what we know. Next time, you'll handle it like a pro.

That's a rough 2 months to start. I hope it didn't scare you away. =(