Your Worst Mistake

Nurses General Nursing

Published

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.

Well. you will not be held liable for those actions you have done. The clinical instructor will be, she must supervise her students on all activities/procedures to be carried out by her students. Here on Philippines(based on books), if the student committed a mistakes, the clinical will answer all the possible liabilities.

But good thing, it never happened to you CI.

actually, in this province in Canada, even as a student i AM considered liable for my mistake... the clinical instructor, the school and the RN assigned to work with me that day would also be liable... everything was explained to the patient and well-documented, so nothing ever came of it... but if the patient had filed a complaint, i would have been (along with the others i mentioned above) brought before our licensing board's Discipline Committee for a hearing... they would determine who was accountable for what... as a 2nd semester nursing student, i probably wouldn't have been held to as high a standard as my instructor or the supervising RN, but i still would be considered accountable...

in the scope of things, my mistake was actually relatively minor (ie: they wouldn't kick me out of school because of it)...

beth :p

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At my hospital year before last there was a nursing student that made a mistake with Heparin. Not sure exactly what happened but it was a serious mistake. The school that she was going to permanently let her go from their program. When the hospital found out about it they went to bat for the student and told the Dean of nursing there that if they didn't reinstate her that they would no longer accept student for clinicals there. They felt that it was human error and that she should not have been dismissed.

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Hugs to all nurses. Sometimes the hardest thing is forgiving ourselves...but we are all very human and perfection is not an option. Something many facilities and managers seem to dispute.

I agree w/ the above!

Thanks to all the nurses here for sharing their stories. My love, respect and admiration to all of us who have one of the hardest jobs in the world- nursing!

Here are by big mistakes-

Working in a busy surgical unit, I drew up a syringe of insulin for a pt (we were not allowed to take the MARs out of the book, or to take the book w/ us to the pt's bedside).

I kept getting interupted on my way to the pt's room. I had two pts in ajoining rooms w/ very similar names. I thought I could trust my memory instead of going all the way back to the nurses' station again to check the pt's name.

Well, you guessed it- I gave the insulin to the wrong pt. She was not even a diabetic.

Thankfully- it was a low dose. I felt like dirt having to tell the pt, the charge nurse and the doc what I did. BS checks q 1 hr all noc. The pt's BS didn't bottom out- she did fine w/ just orange juice w/ sugar and some crackers. I did not have to give her IV glucose. Although she was not injured, I felt really bad for interupting her sleep all noc to check her BS and make sure she was ok. She needed to rest and recover from her procedure- not be woken up all noc for BS checks! The pt did not speak english, so she was unable to tell me off in a way that I could understand. ;)

I think I was supposed to be written up, but wasn't. This was probably due to the unit be in such a constant state of chaos, my charge nurse just forgot to do it.

Another mistake-

Hopsice inpt unit. Again, I was interupted several times on my way to give a pt her MS Contin. I was just giving it to the pt and realized it was the wrong pt. I started yelling "Spit it out! Spit it out!" I cupped my hand in front of the pt's mouth and she spit out the pill in it. The purple coating had not even started to come off of the pill, and it had only been in her mouth a second or so. Thank goodness she was a slow pill taker!

The pt was demeted so, I don't think she knew what almost happened and did not seem at all bothered when I told her "I almost gave you the wrong pill."

I did not write it up, as the med never actually entered the pt's system. I charted that the pill was wasted, due to contamination.

Here's another story I just remebered- I was working nocs at a LTC. I finished my shift and went out to a leasurely breakfast w/ my husband. I didn't get home until two hours after my shift. When I did, I found four frantic messages on my machine. I had left w/ the narc keys in my pocket.

Thankfully, there were only a couple of narcs due on days shift's first med pass. Two pts got their narcs and hour late.

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to nurse1975_25

I understand your concern at the error, and i myself pray every morning that I will always be in the moment with my patients, cause Lord knows how my mind wanders sometimes and I catch myself, but we have SO much to keep track of..everything the patient has going on the nurse has to coordinate..

Anyway, I am posting b/c I know I don't know the whole situation but I think it's too bad you have not worked as an RN since...how do your coworkers feel about it..

If you cannot work in a floor maybe in a office, or business, in a nursing capacity.

basically, people have made similar and worse mistakes and they have stayed, and I think you have the "right" to come back to the profession if you want! :) t.

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I cannot believe that you are not able to get passed the mistake you made, although you are human first not second. There is a reason why there policies are in place (although we all know it isn't anyone with medical knowledge who writes them) And you are not the first to make a mistake....I know there have been worse errors than the one you made. I am not a mathamatician and syringes are not universal (not even insulin ones) I have seccond guessed myself and my calculations too many times to count and could have made a fatal error too. (some hospitals have ready doses and no calculation required which makes us all lazy and then you go to a hospital where you have to do it because the place is not as advanced technologically as others) I certainly know and can identify with your thinking but one day you will realize that nursing had to be a calling for you not simply an experiment in ability. You spent too much time in school (as did all of us) to give up. There are also too many other opions a a nurse than just a medical floor. Find another arena to practice nursing. Forgive yourself:crying2: you owe it to yourself and remember, you did what you could to rectify the situation. No one would blame you.....others have done worse, trust me....and have done nothing about it!!!!!!!!!!!!!!!!!!!

My error has kept me from working since the day it happened. I so terrified that I may make another mistake which may lead to a patients crash or even death. It was a busy day and I was overwhelmed (still no excuse) and my patient was on a sliding scale insulin. I took the blood sugar and she required FIVE (5) UNITS of insulin. to this day I do not know what was going through my mind but I pulled back to FIFTY (50) UNITS instead of the minimal FIVE (5) she needed. I did my checks that it was the proper insulin. I took the patients medication profile to her bedside and compared her armband to the profile and I stated to her that I was there to administer her insulin.

Still not knowing that I had done the error I left the hospital at the end of my shift which was about 45 minutes later. I had helped her with her tray and asked her if there was anything I could do for her before I went off shift. (because sometime report & shift change take a while), she replied no.

I was at dinner with my husband at a resturant and while eating my soup, which was the first part of my meal, IT HIT ME WHAT I HAD DONE! My husband saw my face and asked me what was wrong I immediately grabbed the cell phone and tole my husband to just leave money and drive me to back to the hospital. I called the unit and told them about the error - they said 50!?!?!?!?! I said yes I will be there in 5 minutes. They changed her iv fluid to 50% dextrose and ran it at 100/hr. I stayed with her doing continuous bld sugar tests until midnight. Her BLOOD SUGAR never dropped below 8.1 - in Canada (Ontario) normal blood sugar levels are between 3 and 7.

I was praised and praised for coming back and admitting my mistake. I haven't worked as an RN since.

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:imbar I was working CV recovery, all pt's come from OR with Swan's. They all get q 1hr cardiac outputs. In case any of you are unfamiliar with Swan's or cardiac outputs (aka CO), you have to push 10cc NS through the CVP port on the Swan. Well this particular pt had multiple drips going including Nipride to the CVP port. You guessed it, I forgot to aspirate the Nipride before I pushed the NS. I only disconnected the IV tubing. I was watching the CO trend on the monitor as I heard the "BING-BING-BING" of the arteial line alarming. The art line wave form was dampened so much I first thought I had leaned against the transducer or something simple like that. Then it hit me. I had just bolused my pt with Nipride and his art line pressure WAS REAL. It was 20's/teens and my peripheral vision started darkening, I had an extremely heavy feeling in my chest, probably 7/10 pain scale and thought I was going to pass out. Lucky for me and my pt Nipride has a VERY short halflife. Pressure quickly came up and no damage done. I never left Nipride hooked up to a CVP port again - move it to the white port instead!

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I am so sorry that this mistake has devastated you to the point that you are no longer working as a nurse. We are all human and we all will and have made mistakes. That is part of our humanity! Thank God that your patient was okay. Think about the surgeons that have made mistakes and amputated the wrong extremity and they continue working! I hope and pray that you will forgive yourself and draw on your inner courage and strength to go back to nursing. It is a shame for the medical profession to lose a nurse like you over something like this. Please give yourself another chance!

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My previous message was meant as a reply to you, nurse1975_25

My error has kept me from working since the day it happened. I so terrified that I may make another mistake which may lead to a patients crash or even death. It was a busy day and I was overwhelmed (still no excuse) and my patient was on a sliding scale insulin. I took the blood sugar and she required FIVE (5) UNITS of insulin. to this day I do not know what was going through my mind but I pulled back to FIFTY (50) UNITS instead of the minimal FIVE (5) she needed. I did my checks that it was the proper insulin. I took the patients medication profile to her bedside and compared her armband to the profile and I stated to her that I was there to administer her insulin.

Still not knowing that I had done the error I left the hospital at the end of my shift which was about 45 minutes later. I had helped her with her tray and asked her if there was anything I could do for her before I went off shift. (because sometime report & shift change take a while), she replied no.

I was at dinner with my husband at a resturant and while eating my soup, which was the first part of my meal, IT HIT ME WHAT I HAD DONE! My husband saw my face and asked me what was wrong I immediately grabbed the cell phone and tole my husband to just leave money and drive me to back to the hospital. I called the unit and told them about the error - they said 50!?!?!?!?! I said yes I will be there in 5 minutes. They changed her iv fluid to 50% dextrose and ran it at 100/hr. I stayed with her doing continuous bld sugar tests until midnight. Her BLOOD SUGAR never dropped below 8.1 - in Canada (Ontario) normal blood sugar levels are between 3 and 7.

I was praised and praised for coming back and admitting my mistake. I haven't worked as an RN since.

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heartburn does not constitute and allergy to ativan anymore than nausea and dizziness constitutes allergy to vicodin!!!!!!! these are side effects. yes you should have checked for allergies, which you would have seen on a wristband if your facility has such a thing and if someone was on the ball and put one on him. yes you made a mistake and discovered it, so learn from it. patients need to be educated on the difference between side effects and allergies to meds!:coollook:

i was working ltc and we had just got this elderly couple. the man was very very aggitated. he drew back like he was going to hit me. i place a call to his doctor (without pulling the chart) and his usual dr. was out of town so i got the dr. on call. i told him what was going on with the elder and he tells me to give him 1mg of ativan po now. i call the rn supervisor and get the ativan, take it back to him, he takes it, and i go to write the order. when i pull the chart, in big red letters is allergy: ativan :uhoh3: i called the dr. back and ask him for something else...he gives me an order for a non-narc. med. i go to the nurse i am working with, i feel hot and sweaty and on the verge of vomiting, i become hysterical and she tells me "sweety, we'll fix this...come with me" so we look up how it effected the elder (gave him heartburn) and she tells me that we will keep it quiet just to watch him. he did become very very sleepy...but he did sleep through the night and felt better the next day. i learned very very quickly to ctcfa...(check the chart for allergies)

i still feel guilty about that.

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I was working CV recovery, all pt's come from OR with Swan's. They all get q 1hr cardiad outputs. In case any of you are unfamiliar with Swan's or cardiac outputs (aka CO), you have to push 10cc NS through the CVP port on the Swan. Well this particular pt had multiple drips going including Nipride to the CVP port. You guessed it, I forgot to aspirate the Nipride before I pushed the NS. I only disconnected the IV tubing. I was watching the CO trend on the monitor as I heard the "BING-BING-BING" of the arteial line alarming. The art line wave form was dampened so much I first thought I had leaned against the transducer or something simple like that. Then it hit me. I had just bolused my pt with Nipride and his art line pressure WAS REAL. It was 20's/teens and my peripheral vision started darkening, I had an extremely heavy feeling in my chest, probably 7/10 pain scale and thought I was going to pass out. Lucky for me and my pt Nipride has a VERY short halflife. Pressure quickly came up and no damage done. I never left Nipride hooked up to a CVP port again - move it to white port instead!

Girl, I feel your pain! I broke out into a sweat reading your post! :uhoh21:

This is one of my worst nightmares! Hasn't happened to me (yet) and I pray it doesn't, but I remember other errors I have made and that heavy feeling that comes on when I realize that I have made an error.

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Insulin med error....

That sort of error is WHY it is ALWAYS the best idea to have another nurse check critical medications. Where I work , we must double check with another nurse that we have the right dose, right time, right pt .!!!!

When I was passing meds in a SNF before I went to work in the hospital, I gave insulin to as many as 20 people ALL without having ANYONE to double check me, Iwas ALWAYS very scared, and DOUBLE CAREFUL!!!!

So sorry that incident kept you from going back... BELIEVE me you did the RIGHT thing in reporting the error, I am sure there are MANY MORE out there who let it go and HOPE!!!

Take care, Kathy

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Hi everyone,

I haven't been the boards for a while (been really busy finishing semester 3 out of 4) but found this topic appropriate for me to post in since I have come to the realization that I may have made a mistake this week in clinical. :(

Well basically, a patient I had was scheduled for insulin NPH at 1730 with her dinner and I was so focused on just giving all my patients their regularly scheduled medications since I had to get all new patients in a hurry - about an hour before I started patient care (my other patients were discharged from the previous day). Well, now that I think back on it, I think my patient probably had a sliding scale insulin for regular in her PRN list of meds and when I checked her blood sugar before dinner, it was 230! So I'm thinking to myself "HELLO!!! Why didn't you think that with a BS of 230 that your patient would need some regular insulin coverage for her dinner!!!"

I feel ABSOLUTELY scared right now. I'm thinking I should probably confess this to my instructor (regardless if the patient is still okay and even if no one were to find out)and go visit the hospital tomorrow to make sure my patient is okay. I hope I didn't hurt her or do anything worse ... :(

I feel really dumb right now. I don't even want to tell any of my nursing friends because they'll think I'm going to make an awful nurse if I can't even do something so simple as to give insulin.

Thank you everyone for letting me vent and also for sharing your mistakes as well. I know we're all human but I just feel like I need to be really "on top" of things if I want to be a good nurse.

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