Your worst mistake

  1. 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.
    Last edit by Yeti1313LPN on Apr 9, '04 : Reason: Spelling Error
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  2. 390 Comments

  3. by   Berta
    As a student, I know that I WILL make mistakes. I applaud you for realizing and admitting your mistake. We all make mistakes..The single most important thing is that we learn from it and don't repeat it again.
    Berta
  4. by   J Lynn
    i'm also a student and i'm terrified about working in a hospital because i know i will make a mistake sooner or later. i hope i work with understanding nurses who will not make me feel like i shouldn't be a nurse. thanks for sharing your story.
  5. by   Kudra
    actually, my worst mistake to date was pretty similar to yours, mwcia12... it was my 1st semester of my RN course and i was looking after an elderly gentleman who was due for a transfusion... we were waiting on the blood to come up from the lab and the hospital's policy was that students could not hang blood, so i went to lunch... while i was at lunch, though, the blood arrived and the RN i was working under had hung it... but as soon as she had hung it, she went to lunch as well and left the RPN in charge of monitoring the patient for a transfusion reaction...

    so, i get back from lunch about 30 minutes later and i asked the RPN for report and she said that she had checked his vitals and everything appeared to be fine... so i go into the room and do the classic mistake of focusing on the lines/machines hooked up to the patient instead of really assessing him... i stupidly overlooked assessing the site, but i asked the patient if he had any complaints or pain and he said no...

    well, 10 minutes later, the patient's son comes out to the desk where i was charting to find me... he said the patient's arm was really hurting and it looked bruised... and my first thought was "crap, it infiltrated!"... sure enough, it had... the poor man had about half a unit of blood in his tiny little arm... it just looked horrible... so i stopped the infusion, elevated the patient's arm on a pillow and called my clinical instructor... my instructor was pretty cool about it and we applied warm compresses (as per hospital policy) to the site and restarted the blood in his other arm... we explained everything to the patient and his family and they were really understanding about it all... i felt SO bad...

    to make matters worse, the RPN totally flipped on me saying that i was negligent because i was responsible for the blood, not her... i think, in hindsight, that she was worried that the mistake would come back on her because she was responsible for monitoring it while the RN was away, and the half a unit would have started infiltrating before the last 10 minutes that i returned to the floor and checked the patient... but, of course, being a student i felt like i had screwed up royally... i think that was the only time i ever contemplated quitting the program...

    anyway, i feel pretty lucky that it was my biggest mistake to date because there definitely are a lot worse things that could happen... but you can bet to this day, when i do an assessment, i start with the patient and work my way back to their lines rather than focusing on the pumps anymore!

    beth
  6. by   casper1
    Nurses are only human they make mistakes. When I first graduated from Nursing school I worked on a floor where you were written up for everything, a missed
    suppostory or a missed bath. It didn't matter that we were new grads with 8 patient assignments. I could'nt sleep at night terrified that I missed something and would be in the Nurse Managers office the next day. We heard on a regular base " Nurses can not make mistakes."

    You learned from your mistake I bet you will never make that mistake again. We all learn more from our mistakes than our successes. Your manager saw how upset you were she knew it was an honest mistake and you were very upset. I've been a Nurse
    now for 15 years and I honestly feel that most nursing mistakes are the fault of poor administrated policy, poor staffing.
  7. by   BabyRN2Be
    As a student-to-be, my worst fear is making a medication error. I haven't even started school and I've been reading chapters in nursing books about drug calculations, and I practice these calculations when I can. I can see myself as a nurse triple, quadruple checking to see if I've got the right medication, delivery route, right dose, and most of all, right patient!
  8. by   canoehead
    I had an IV infiltrate on an infant once. I could see the site through the window, but didn't want to even go in the room to touch her because she had been so hard to settle, and it was a brand new site, so I assumed it was OK. After seeing that poor childs arm after 2 hours I will never assume anything again. It must have been excruciatingly painful.
  9. by   LolaRN
    One time I miscalculated a dose of Roxinol and gave the patient 4x the dose that she was supposed to get. I had to give her Narcan. I was ready to turn in my lisence. I felt terrible. Now I have someone double check any calculation dose for a med that I haven't given before. Probably drives my coworkers crazy but I will never forget the sick feeling in the pit of my stomach.
  10. by   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.
  11. by   Noney
    My worst mistake is something that almost made me quit. I was new to tele. I had gotten an admission during the night. He came to the floor with a pt of >110 INR >10 and ptt >140!!!!!!! All the ER doc wrote was No coumadin and he said he had called the attending prior to admitting. Any way the pt was in SR with a BBB. After I had asseessed with I left the room to do something I came back about 20 minutes later and the stopcock on his IV had came loose and he was lying in a pool of blood. I mean a pool it was so much we had to get a new bed. His blood was running out of the IV so fast . Welll anyway he started have frequent PVC.s while we were cleaning him up. He what I thought was a 27 beat run of V-Tac, then went back to SR with BBB. However, it wasn't Vtac it was a junction rhythm was a bbb. I called the house dr and he ordered a Lido drip and vit K. I gave both.


    I felt so bad later. That's when I decided you have the be assertive when things don't feel right. I should have demanded the ER doc treat before sending the pt to the floor. I should have called the attending myself after the pt arrived, I should have made the house dr come to the floor. And I should have made a more experienced RN look at the strip. I learned alot from that experience. Thankfully no harm came to the pt.


    Noney
  12. by   SouthernLPN2RN
    My worst mistake was when I gave a nursing home pt who'd had a hip done his pain and BP med at the same time without first checking his BP. I was usually supervigilant about checking bp's before I gave meds. Anyways, after an hour, his BP was 88/55 and I was FREAKING!!! I didn't care if it was the middle of the night, I still called the surgeon. I trended him, had him on q15 min vitals and basically prayed all night. I just knew I had killed that pt! He recovered fine, but scared me to death, especially since he couldn't communicate other than moans due to advanced dementia.
  13. by   MandyInMS
    I gave a double dose of antibiotics to a 1 y/o IM..being a fairly new nurse and NOT used to working with peds pts,I was unsure of the dosage prior giving and talked with the supervisor..I gave what I understood her to tell me to..she said I misunderstood her...talk about being scared sh!tless!! OMG..I cried,and cried, and cried some more..called the Doc, who was notorious for being a butt..and he was great..guess he could tell how 'tore up' I was about it..all ended well thank GOD..no harm to the baby..but still gives me the willies to this day.
  14. by   moia
    As a student I was on my second med day. It was a huge medical unit with never ending discharges and admissions. A new admission came in and I gave her all her meds as ordered..I never even looked at the note attached to the recovery room MAR that clearly and obviously said the patient had recieved her meds before transfer. To this day I can't believe I missed this huge note in permanent black magic marker.
    I was horrified but I got lucky because the nurse before had given her the wrong dose as it had been increased on the doctors orders...we found this out when we told the doctor I had given her a second dose..he was confused because he had ordered the dose I was sobbing over. He had a good laugh, I got the scare of my life and learned a painful lesson that you should always sign the MAR BEFORE giving the med...I know nursing teachers say not to but to hell with that...I look for my place to sign and have more than once in my career discovered someone else already gave the med..especially when it is a narcotic.

    I did see a doctor kill someone once , it was really awful because I had begged that doc not to give that drug because a week before he had nearly died from it. He ignored me and I refused to hang the drug so he convinced the charge nurse to do it after giving me a really hard time. It took 5 minutes to kill this poor man.
    I had to go to about 5 meetings to explain why I refused a doctors order and how I knew the patient would die. Thank God for really good charting because that doc was trying to blame the nurses for his error but I had 3 really good witnesses including another doc who actually backed me up. I was really really surprised that he did but he has always been a good doc. The charge nurse who hung and infused the med really got grilled really badly by everyone. I wasn't exactly supportive either because at the time she was really obnoxious when I refused to give the med and she told me she was going to write me up and worse accused me of refusing to provide care for my patient.
    Sometimes you may have to make a stand and accept the fallout. Even if the patient has no serious repercussions doesn't make you wrong, it makes the doc very lucky.

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