Mistakes we have made

Funny how it only takes one time... In the goof I wrote about, I was new to psych and had only been out of school about 6 months and was soooo careful (or so I thought) about everything I did but allowed myself to be distracted by another nurse talking to me and forgot to sign off on the meds I'd just pulled. She was an older no-nonsense woman who treated everyone under 40 or so like kid and I allowed myself to be intimidated by her.

sharpeimom

We had a brand new nurse come to us and tell us that she had to go down to pharmacy to get morphine. We are a surgical floor so usually have plenty in the narc cabinet. We asked her if she'd looked in the cabinet and her response was "yes, but there's only morphine sulfate in there, the order is for morphine." WOW!!! She was fired several days later for giving dilaudid instead of morphine.

It's kind of nice to read about other people's errors and realize you aren't the only one who's done something careless or just plain stupid from time to time.

I took care of a congenital heart patient once who pretty much chronically received blood transfusions. He got one about every 2-3 days. I took care of him one day, and his mother said to me, "When is he going to get his blood today?" I was a little puzzled, because I knew he had just gotten blood the night before, but I went and checked my orders and sure enough, there was a blood order, with that day's date on it, timed for 1200. It was around 1600 or so, so I felt like it was actually late. I ordered the blood, got it, checked with another nurse, and gave it. The next day I came in and got my butt chewed by the night shift doctor because apparently the blood I gave was the order she had written the night before and that was given the night before. Instead of using military time, like she was supposed to and writing 0000 or 2400, she wrote 1200 and didn't specify AM or PM. And then the night nurse who gave it didn't sign it off. And the blood blank didn't notice that it was the exact same order that had been sent to them the night before.

I told the night shift doctor that if it was anyone's fault it was hers, because she should have used military time ... and that this proved why hospitals use military time to begin with. And, compounding her error was the fact that the night nurse didn't sign off the order, signaling that it was complete. But the doctor kept insisting that *I* was to blame because I should have recognized her signature on the order and realized that she was the doctor on nights that week and not the one on day shift. Whatever. Luckily, my manager didn't see it that way.

It shows you how important it is to sign off your orders after you complete them, though.

[quote=DeadHeadRN;3341908]We had a brand new nurse come to us and tell us that she had to go down to pharmacy to get morphine. We are a surgical floor so usually have plenty in the narc cabinet. We asked her if she'd looked in the cabinet and her response was "yes, but there's only morphine sulfate in there, the order is for morphine." WOW!!! [quote]

Thats scary! I would like to know where she works now.

One of my favorite "errors" is when I was in nursing school, I was giving my first tube feeding. It was going on a pump. I went to check a residual and give meds, so I unplugged the TF and paused it. Instead of connecting it back to the patient's Dobhoff, I left the TF dangling over the side of the pump, disconnected, and I restarted it. About 20 minutes later I go into the room to do vitals, and I realize that the patient's bed is covered in TF!

Reading your stories made me smile, whew.

I'm a new RN. I had a pt on CBI, I've been emptying his CBI frequently. Then he said he feels pain, like cramping in his bladder, so since he's post-op I thought, ok he needs pain med, so I gave him Percocet. Few minutes later, I asked if he feels better, he said from 9/10 now it's 3/10. So ok, I told him to call me if it's not getting better. I checked the CBI, not quite full yet. Then I saw his MD in his room, he asked me to irrigate the pt's foley, coz it was clotted that's why he's in pain. He was mad, I feel guilty, stupeed and didn't get a good night sleep for few days hoping I didn't perforate that pt's bladder. He didn't!

One day, early morning I checked my pt's labs, called the MD for low H/H. He said he ordered a blood for the pt the other day. So I checked the chart it was ordered yesterday but it wasn't given, and even the night shift nurse that gave me report didn't mention anything about it.

I sent urine for UA from the wrong patient (no biggie he was dc'd anyways)
I had some minor medical errors (from now on, I'll be more careful)