Mistakes we have made

OK, here's a couple more:

Back in the days when we put heparin in flush bags, I went to mix one up. The concentration in those days was 1000 units of heparin in 500cc of NS. Not only did I accidently draw up 10,000 units of heparin, the nurse I checked it with didn't catch my error. So instead of having 2 units of heparin per cc, the flush had 20 units. Flush bags hang until they run dry (or 96 hours have passed), and in that time the platelets got awfully low. I caught my own error when I went to replace the bag and found the heparin vial I'd used, correctly dated, timed and initialed -- but the wrong concentration of heparin! I wrote myself up and threw myself on the mercy of my manager!

I learned never to leave an unsupervised resident in your patient's room. Years ago, I was working in a cardiac surgery ICU at a university teaching hospital. I had two patients in a double room, one of them ready to transfer out and the other a fresh post-op. We were short staffed that day, and when the time came to transfer my stable patient, there was no one available to watch my fresh post-op. Because there were two computers at the mini substation in that room and I was only using one, Charlie, one of the residents was parked back there looking at lab results, X-ray images, etc. When Charlie volunteered to watch my patient for the few minutes it would take to wheel the other patient out to the floor, I reluctantly accepted.

"Don't worry," he said. "I know ACLS and I can call a code. I can even run a code."

I transferred the patient just as quickly as I could, and ran back to the room to find Charlie and a medical student standing over the bed of my fresh post-op. I don't remember which I noticed first: that they were suctioning bloody yuck out of the patient's chest tubes or that there was bloody yuck dripping from the ceiling and splatting on the clean, white sheet covering my patient from the thighs down.

It seems that Charlie and the medical student had neglected to put a suction cannister on the chest tube suction tubing (tubing going directly from the wall suction to the Pleurevac) before suctioning out the chest tubes. The stuff they were suctioning out went directly into the wall suction and got sucked up into the ceiling. The room was closed for WEEKS while bio-engineering and maintenence cleaned up the mess and got the suction functional again. And I never ever left an upsupervised doctor with a patient again.

Of course the occaisional doctor has managed to sneak into my patient's room while my back was turned.

About a year ago I got pulled to the NBN. I took a baby out to nurse about 0200. While that baby was out nursing another new mother called for her baby. I could "not" find her baby. I was in a panic! I soon realized the baby I had taken out to nurse was her baby and not the baby of the woman who was nursing the baby. I had to go get the baby, turn on the lights to show her it wasn't her baby. Then I had to tell the mother of the baby that the baby had been nursed by another woman. I had to call the pediatrician and I had to fill out an SOE. I felt totally stupid, embarrassed and incompetent. I haven't been pulled to the NBN since.

What a good topic to start, and you're right, if you don't learn by your own mistakes, you can learn from others who have had them. I work on a cardiac floor and there have been several things I can tell you about...

My first huge mistake was done shortly after I was on my own from orientation. During report, I was told the patient was to receive 2 units PRBCs, the secretary had written it on the MAR and I was trusting the word of a more experienced nurse. Well, go to hang the blood, patient has a temp. Got orders to treat that, then the BP was high, so call and get orders for that. As the second unit is almost done, something made me go back and look at the order. The order read Type and Cross for 2 units of PRBCs. There was never a transfusion order. Terrified, humilated, and dumbstruck, I had to call the MD and explain everything to him. I got quite an earful and now I always check blood orders before giving them.

Another one that happened on our floor, patient had a heparin drip running and somehow the pump got set to 99ml/hr instead of 9ml. Almost all of the 250ml of heparin had been infused by the time it was caught. Now our protocol is that two nurses have to sign off of heparin adjustments.

Another incident was the monitor tech was calling a nurse about a rhythm, believe it was bradycardia. And the patient was treated for it. However, the actually monitor box was on the wrong patient, so the wrong patient got treated. Another hospital procotcol, we now have to check each patient's tele box number with the monitor tech to assure we are looking at the right person. Oh, and treat the patient not the rhythm.

Another one told to me was there was an order for Furosemide 40mg IV and Phenergan 40mg IV was given instead. Patient ended up in the NICU unit on a vent.
This has probably happened to more than one of us, but you have a flush bag set up with antibiotics piggybacked in, and when you come back to check, you've been running the flush in instead of the antibiotic.

Decades ago and far, far away, I worked at an institution that had just built a big, beautiful new hospital. I was there the day we moved in to the new CCU. Patient in room 2 is lying in bed sleeping peacefully when the whole code team arrives, slapped on the paddles and shocked him. Still VT, but the patient is awake and pretty peeved. So they sedate him and shock him again. Still VT, and his art line pressure is dropping rapidly. By this time, he's sedated and not all that responsive. So as they're getting ready to shock him a third time, someone calls out "WAIT! I've got a pulse!" Pulse is 70 (not at all correlating with the rhythm on the monitor) and blood pressure is 110/60. A little low, but OK.

Meanwhile, the patient in room 3 is deader than a doornail and a lovely shade of blue. Turns out that the wiring was screwed up . . . signals from room 3 were displayed as having come from room 2 and vice versa. So the patient in VT died and we treated a healthy patient in NSR. Moral of the story -- check the pulse first!

I once worked in a hematology unit where we drew labs from Hickmans every morning and flushed them with 10cc NS. This was before the days of prefilled saline syringes, so pharmacy used to mix up our saline syringes and send them up in a bag of 10. (They did the same with the KCl that we added to our IV bags. Perhaps you see where this is going.) Drew my labs one morning, flushed the Hickman with my 10cc "saline" flush and the patient starts screaming that "it burns!" and promptly arrested. Afterward, it was determined that I'd flushed the Hickman with 20 mEq of KCl drawn up and labeled by Pharmacy as flush solution. That was bad enough, but it happened three more times that same week to other nurses, once to the SAME patient, who KNEW what was happening and survived a second code.

Moral of that story: If you know there may be a problem with some of your "flush" syringes drawn up by pharmacy, send them BACK to pharmacy and draw up and label your own! I'm sure there are other morals to that story, too, but that's the one that grabs me right now.

I haven't found my first RN job yet, but I've already made some mistakes.

I volunteer in an ED. Occasionally, I move patients. One busy day, the triage nurse asked me to move a patient from from room 1 to room 7, and bring the chart. I walked into room 1, introduced myself, and said I was moving her to room 7. I couldn't find her chart, so I went back to talk to the nurse. She said the patient in 1 needed a wheelchair and the chart. I said "The patient's on a stretcher." She insisted I move the patient. So I did.

The ED had 3 triage rooms and about 50 treatment rooms. I moved the patient in treatment room 1. She wanted me to move the patient from triage room 1. Since then, I always make sure I have the name of the person I'm supposed to pick up.

I once did a fingerstick blood sugar without wearing gloves.

I once changed a baby's diaper without wearing gloves.

One of my complex med-surg patients was gasping for air, with RR of 32 and a sat of 92. I told the nurse she was gasping for air and her respirations were 32. She responded "Yeah, she's been running that." I couldn't find my instructor, so I charted it. The doctor was very concerned, and they ended up calling an "almost code" and transferring her to the ICU.

The nurse said "You need to tell someone about stuff like that." I replied "I told you about her respirations." I was already on clinical probation, and I got written up. I explained my side in writing. After that, I told the nurses about anything the least bit abnormal. They were annoyed, but I passed clinical.

Another day, I heard during report that my patient was discontinuing an infusion after the last 100 cc. When the pump went off, I checked it, paused it, and asked the nurse if I should disconnect it. She said yes. With my instructor next to me, I disconnected it. I did something wrong, because the next thing she said was "You just contaminated the tubing." It turned out that the patient was supposed to get another 100cc. They ended up using a new bag and tubing.

I did a rotation at a rehab hospital, on a floor with 40 patients, a lot of diabetics, a lot of people on corticosteroids, and 3 glucometers. The MAR had 3 sheets, including 1 for diabetics.

My patient was at lunch, but he needed a FBS before he ate. I grabbed his diabetes sheet, intercepted a glucometer, and took him to a corner, trying to be polite (everyone else thought it was a good idea). The glucometer shut down, and I had to track the nurse down to set it back up. By the time that was done, lunch was over, and my patient was back in his room. My instructor told me to grab his MAR, so I did. I matched the patient numbers on the diabeters sheet with his bracelet, got the FBS, and administered insulin.

When I opened the MAR to put the diabetes sheet back, the sheet was already there. I had the wrong MAR. Fortunately, I had the right diabetes sheet, but it was very scary. The hospital had 3 different sliding scales; If I'd used the one in the MAR, instead of the one in my pocket, I would have given him 15 units instead of 5. That incident reminded me to always follow the 5 Rights, not matter how busy you are.

I was a fairly new nurse and my soon-to-be discharged psych patient was going home to spend the day with his family just as I was coming back from lunch. I had made up his meds and put them in the plastic containers we used just for day pass pts., and gave them to his wife for later and off they went. They'd been gone about half the time when the phone rang and it was my patient. He had a "quick question..." He had just taken his meds and wanted to know whether those meds would "be safe with the other pills that other nurse gave me before I left the hospital?" Huh? Turns out, I had forgotten to sign my meds out so the other nurse thought she'd help me by giving them for me just a bit early. All I can say is that I'm grateful he forgot about them and ended up taking the second batch nearly four hours late. We were both reprimanded but not written up. The good news is that it made me compulsive about meds giving.

sharpeimom

I am continuously amazed at how nursing students are treated in school.

As medical students, we are routinely abused, harassed, and publicly humiliated. This is normal and expected.

But when medical students make clinical errors (failing to report an important finding, screwing up an order, missing something on a physcial exam), they are not formally punished, because this is expected. Students screw up, that's why they're students. You can and should berate them for it, yell, given them extra work, whatever. But you don't sanction them formally or kick them out, because making mistakes is a normal part of learning.

I am just blown away that a nursing student could be put on probation or written up because they didn't make a big enough deal about a patient's vitals or breathing pattern. Yes, it is important that this finding be caught and addressed, but it is the responsibility of the person with the license, not the student who is still learning what matters and what doesn't. When a clinical finding is missed, the preceptor should be held responsible, not the student.

It is a shame that y'all are subjected to that kind of learning environment.

Oh, lilpo - I read your post and just had to throw in my .02. I figured that had never happened to anyone but me. I was working on an ICU unit at a LTAC unit, and the MD came in to put a CVL while I was at lunch. The charge nurse assisted and the MD wrote an order, "OK to use CVL for TPN and Lipids." I was looking back after the patient was done and didn't see xray results. It had not been done, so I ordered it. The radiologist called immediately after he saw the film and said "Do not use it. Do not touch it. Call the idiot who placed it and tell him he put the line into the carotid!!" He was so freaked! He wasn't a happy camper when I told him the MD had already started all his IVs before he left the unit.

I called the MD that placed it and told him about the radiologist's call, and he just said, "Oh, it's OK, you can pull it. Just put a bandaid on it". A freaking bandaid on a carotid artery??! No thank you!!!

I was working in a LTC and had a note saying Flu vaccine was in and to try to get as many as possible done. I gave 20 and completed all the documentation. Then discovered that the vaccine I gave was from the previous year that nobody threw out when it expired. I had 20 med error reports to do plus the embarrassment of notifying the MD's and families of the error. I'm compulsive about checking expiration dates and disposing of expired meds now!