Your worst mistake - page 8

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   nursemjb
    Quote from nurstudnt546
    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.
    Did you write it down anywhere? If not, I still think it would be better to keep it on the QT. You can't change it now it's been too many hours.

    A little less insulin is better than too much. I've had many more problems in my 12 years of nursing with patients bottoming out on blood sugars than elevated ones. The last one wasn't my patient but I helped a nurse recently with a patient who had a BS of 35. Let me tell you it was scary......

    The scariest for me was a student in middle school who didn't take her diabetes seriously and varied between the 40's to the 600's......now that was no fun at all.

    Keep your chin up......you can write back again and I'll answer.
  2. by   nurstudnt546
    Quote from nursemjb
    Did you write it down anywhere? If not, I still think it would be better to keep it on the QT. You can't change it now it's been too many hours.

    A little less insulin is better than too much. I've had many more problems in my 12 years of nursing with patients bottoming out on blood sugars than elevated ones. The last one wasn't my patient but I helped a nurse recently with a patient who had a BS of 35. Let me tell you it was scary......

    The scariest for me was a student in middle school who didn't take her diabetes seriously and varied between the 40's to the 600's......now that was no fun at all.

    Keep your chin up......you can write back again and I'll answer.

    Yeah, blood sugars that low would be scary for me too. So I take it that you're either a school nurse or a pediactric nurse? (Am I way off?)

    Well the fact is that I did chart it (both on paper and in the computer), under my own name/login, so there's no way around that. But I had really communicated with my nurse that evening and am sure I told her what the blood sugar was. I guess it never came up in her mind to remind me about checking for sliding scale coverage either - which I know is still no excuse for my mistake. I can't blame anyone but myself.

    I just hope I don't get kicked out of my program (which I don't think will happen because another student actually had a med error, involving Dig, and that particular student is still in the program, she just got a "write-up" sort of thing).

    Thanks again. I'm starting to feel a little better.
  3. by   nursemjb
    [QUOTE=nurstudnt546]Yeah, blood sugars that low would be scary for me too. So I take it that you're either a school nurse or a pediactric nurse? (Am I way off?)

    Well the fact is that I did chart it (both on paper and in the computer), under my own name/login, so there's no way around that. But I had really communicated with my nurse that evening and am sure I told her what the blood sugar was. I guess it never came up in her mind to remind me about checking for sliding scale coverage either - which I know is still no excuse for my mistake. I can't blame anyone but myself.

    I just hope I don't get kicked out of my program (which I don't think will happen because another student actually had a med error, involving Dig, and that particular student is still in the program, she just got a "write-up" sort of thing).



    In my 12+ years of nursing I've worked in the OR (adult and pediatric), home health, med-surg, rehab (both kinds), ortho-neuro, oncology, telemetry, PCU, SNU, special procedures, and school nursing. Most of my hospital nursing has been per diem for a nursing agency.

    Before I was a nurse I worked as an engineer in the Materials and Processes Lab at General Dynamics. I did research and development for all materials used on the F-16 aircraft.
  4. by   nursemjb
    [QUOTE=nursemjb]
    Quote from nurstudnt546
    Yeah, blood sugars that low would be scary for me too. So I take it that you're either a school nurse or a pediactric nurse? (Am I way off?)

    Well the fact is that I did chart it (both on paper and in the computer), under my own name/login, so there's no way around that. But I had really communicated with my nurse that evening and am sure I told her what the blood sugar was. I guess it never came up in her mind to remind me about checking for sliding scale coverage either - which I know is still no excuse for my mistake. I can't blame anyone but myself.

    I just hope I don't get kicked out of my program (which I don't think will happen because another student actually had a med error, involving Dig, and that particular student is still in the program, she just got a "write-up" sort of thing).



    In my 12+ years of nursing I've worked in the OR (adult and pediatric), home health, med-surg, rehab (both kinds), ortho-neuro, oncology, telemetry, PCU, SNU, special procedures, and school nursing. Most of my hospital nursing has been per diem for a nursing agency.

    Before I was a nurse I worked as an engineer in the Materials and Processes Lab at General Dynamics. I did research and development for all materials used on the F-16 aircraft.
    Do you want to see a precious boy .....my grandson and my daughter...
    http://mywebpages.comcast.net/Threesprys/index.htm
  5. by   nurstudnt546
    Oh boy, nursemjb, you weren't kidding when you said "precious." Little William is absolutely adorable. In one of the pictures he looks like a little doll with his big blue eyes, pink lips, and all that nice hair. What a little cutie!


    I have a little one of my own. He's three going on four in August (don't have any pics on the computer at the moment). Looking at your grandson's pictures makes me want to have my second one because at my son's age, they begin to lose those cute baby features (i.e. nice big round cheeks, and big bright eyes). How old is little William Gabriel?
  6. by   nurstudnt546
    Oops! nevermind about his age. I just remembered that his birthdate is on the web site. So he'll be turning three this November - enjoy all the "baby-ness" now while it's still there!
  7. by   nursemjb
    Quote from nurstudnt546
    Oops! nevermind about his age. I just remembered that his birthdate is on the web site. So he'll be turning three this November - enjoy all the "baby-ness" now while it's still there!
    The only bad thing is that he lives so far away from me. I haven't seen him since Christmas. Both of his parents are in the military......

    Where do you live? How old are you?
  8. by   Yankee in Texas
    My first mistake as a nurse was deciding to work 2nd shift (3-11p) its the shift with no life.

    Seriously. I made three mistakes in a 24h period.

    #1: I gave 3mg of dilaudid when the order said 2mg. By God's grace the
    pt wanted the dosage increase and the doctor increased it to 3mg that
    day.

    #2: That same pt I initiated the pca for dilaudid and entered the
    concentration as 1mg/ml instead of 0.2mg/ml = the pt got 1/5 of the
    order dose. (3 nurses checked it that day was well)

    #3: This one upset me more...the pt was in a rush to be dc'd home...I
    failed to remove his IV assess/hep-lock.
  9. by   TechieNurse
    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)
  10. by   ktwlpn
    Quote from TechieNurse
    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)
    The first rule of emergency medical services is to secure the scene-their safety is paramount.You could have gotten hurt yourself had you tried to be more assertive
    .You have NOTHING to be forgiven for-you were surrounded by drunks and you did all you could have done.Had you resisted the brother's attempt to help he would have smacked you flat.ETOH and the brother killed the victim-not you...As for the rest of the family do they blame you? Has it affected your marriage? You can go back and get the proof you need to clear yourself of blame but is it worth it?Will it cause more harm to all involved? I am betting the brother does know what he did-why not talk to him with your husbands help? Have you ever gotten counseling ? I think you should...You did all that you could and you have to believe that before you can heal yourself......
  11. by   nursemjb
    Quote from ktwlpn
    The first rule of emergency medical services is to secure the scene-their safety is paramount.You could have gotten hurt yourself had you tried to be more assertive
    .You have NOTHING to be forgiven for-you were surrounded by drunks and you did all you could have done.Had you resisted the brother's attempt to help he would have smacked you flat.ETOH and the brother killed the victim-not you...As for the rest of the family do they blame you? Has it affected your marriage? You can go back and get the proof you need to clear yourself of blame but is it worth it?Will it cause more harm to all involved? I am betting the brother does know what he did-why not talk to him with your husbands help? Have you ever gotten counseling ? I think you should...You did all that you could and you have to believe that before you can heal yourself......
    I agree with ktwlpn, you did what you could. There are so many sad/tragic situations exacerbated by alcohol.......I think grief counseling would help you.....
  12. by   TechieNurse
    Quote from ktwlpn
    The first rule of emergency medical services is to secure the scene-their safety is paramount.You could have gotten hurt yourself had you tried to be more assertive
    .You have NOTHING to be forgiven for-you were surrounded by drunks and you did all you could have done.Had you resisted the brother's attempt to help he would have smacked you flat.ETOH and the brother killed the victim-not you...As for the rest of the family do they blame you? Has it affected your marriage? You can go back and get the proof you need to clear yourself of blame but is it worth it?Will it cause more harm to all involved? I am betting the brother does know what he did-why not talk to him with your husbands help? Have you ever gotten counseling ? I think you should...You did all that you could and you have to believe that before you can heal yourself......
    Hi All
    Just to clarify a bit...I did end up marrying into that family, but it ended in divorce a few years later. Did this incident ever effect my relationship with my in-laws? Not sure, probably though. I never spoke to anyone about what happened, especially not the family. I didn't think it served a purpose for them to blame another son instead of me. Besides, it would only sound like I was deflecting responsibility.
    I moved out of bedside nursing and am content working in Informatics. But this was the root cause of why I switched...
    Thanks
  13. by   KacyLynnRN
    I have been an LPN for 1 1/2 years and made 2 errors...
    #1. Forgot to give a pt. his 2100 dose of 60 units of Lantus insulin. Realized my error at 0230 while doing a 24 hr. chart check. I thought I was going to throw up, and felt like I was seeing double for a minute when I realized what I'd done! The RN I was working with was so sweet, she offered to call MD for me, but I wouldn't let her do it. I didn't want her to take the heat for my mistake. I checked the pt.'s BS which was 300-something, (it had been running in the 200's pretty regularly) called the Dr. on call, which I was sure I was going to get screamed at. He ended up being very nice, just have me a one time order for Humalog and told me to recheck the pt.'s BS in 2 hours, if it was >300 call him back. It wasn't. I filled out an incident report and never heard another thing about it.
    #2. This was was the worst by far....I had just started working the day shift and was getting used to pt.'s being gone for procedures, etc. Had a renal pt. return from a lumbar puncture, his baseline was confused and a little drowsy, and he seemed normal (for him) then. The nursing assistant who brought him back from the procedure said, "there are some orders in his chart." I looked at the chart, it was flagged, and there was absolutely no marks on the order that anything had already been done with the orders. One of the orders stated "Dilaudid 0.5mg IV now" I double-checked the pt.'s MAR (med book or med pages) and nothing was written about any Dilaudid already being administered. I told the RN I was working with there was an order to give the pt. Dilaudid and she looked at the order as well. I gave the pt. the Dilaudid and a few minutes later, his daughter came and got me and said "my Dad looks really drowsy" I went into the room and horror of all horrors, he was drolling, unresponsive, and a quick check of his O2 sats showed he was in the 80's. Long story short, he ended up getting transferred to ICU. I was a wreck. I went home and cried all night long to my boyfriend, told him I was sure I had killed the man. At this point, I still did not realize the Dilaudid had already been given. When I returned to work the next day, my boss talked with me and told me that after I left, they called the MD and he told them the nurse upstairs assisting him with the procedure had given the Dilaudid 0.5mg! So I had actually double dosed the pt. The pt. was still in the ICU but stable. A few days after that my boss told me there had been an investigation into it, and it was determined that the nurse assisting the MD with the procedure did not follow the hospital's policies, she should have signed the order off or at least marked "given" next to the Dilaudid order so I would have known. My boss assured me over and over it was not my fault, there was no way I could have known it had already been given. The pt. ended up recovering and getting discharged. I still look back and feel guilty though, and wonder if maybe just somehow I could have figured out he had already gotten the Dilaudid once. I hope nothing like that ever happens again in my nursing career!!!

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