Mistakes we have made - Page 6Register Today!
- Jan 1, '11 by MomRN0913This is a great thread, because I still beat myself over med errors.
As a new grad off orientation I was a float nurse. Bad idea. You get crapped on, the worst assignments, and no one to really go through. One night I had 2 confused patients, jumping out of bed int he same room on a med-surg floor, and a patient (amongst 5 others) who had a hernia repair complaining all night of pain on PCA morphine. At 5am, the PCA was beeping it was empy, I had 2 patients ready to jump out of bed. NONE helping me at all. I got my PCA out of the pyxsis.... turued out I took out PCA Meperidine instead of Morphine. A very nice surgeon caught it. he said "umm, maybe this is why the patient is getting relief" when itold him all night he was complaining. It was up for 2 hours, which meant he got about 3 mg of demerol, which does do nothing. I self reported. I was very reassured by the nurse manager and no harm was done. I dont know if it had to do with me, but shortly after, the meds were being profiled int he pyxsis under the patient names. when I made the mistakes, they were not, we could take out any med for any patient.
next one: same med surg floor during floating. We would flag our med pages that needed to be given. Well, 2 pages stuck together and when I looked for the PRN order, I saw the patient name, turned ot the back and found "Xanax 1 mg" got it out of the pyxsis (patient was very anxious and it affected her breathing) went to sign it and the pages got un stuck. When I looked, I only saw Ativan 1 mg PO. There are no names ont he back where the PRN orders were. I self reported again, no harm done, it was a system error. The Xanax was for a different patient. It actually had a good outcome, the patient slept nicely, still aorusable and her sats wen from 89% to 98%, which I am very lucky for.
I went to MICU after 4 months of floating, because I hated it. i got wonderful rpeceptorship and learned sooo much. I did one set a rate wrong on a pump of diprivan. I set the piggyback int he diprivan channel instead of he KVO channel at 100cc/hr. I caught it fast, when noticed he was VErY sleepy which he normally wasn't even on the milk. Stopped it altogether and he woke up Fast. had to turn it back on.
A physician wrote an order for a patient with a K of 4.6 to give one run 20meq IV. A collegue recieved this from the next shift, it was endorsed over. My collegue questioned it. "this doesn't seem right, the K was 4.6?" The nurse who was endorsing, a very thourough nurse actually gave a reasoning it prob being ordered because th patient was 3rd spacing and they were trying to get the extracellular fluid, blah, blah blah. Well, the nurse didn't feel comfortable giving it (his BUN and Creatinine was elevated as it was), she called the MD, who admitted he looked at the wrong patients labs when he ordered it. No KCL given.
A patient was on Dopmaine.. the pharmacy sent up a bag labeled Dopamine for a patient, only it was actually DOButamine. Nurse caught it before it was hung.
i had a patient on Humalog insulin. Pharmacy printed label said Regular insulin on the Humalog bottle.
Another time I received a code from the floor. We hung up Levo as per MD verbal orders, another nurse hung it for me. Standard is 4mg/250. That bag ran out and I sent for another one to the pharmcy. BP was dropping and I noted the drug ont he bag, but not the concentration. When the MD wrote the order, they wrote for 8mg/250. I didn't change the concentration int eh pump. it wasn't running too high and it didn't affect the BP because th patient was hypotensive as it was, but it was def an error which was caught by the oncoming nurse, who just changed i in the pump and kept it at the same rate, because that was what the patient needed. but it could have been worse.
I came in to a patient on a heparin gtt for a PE. I noted it at 30ml an hour. it was supposed to be 8ml an hour. I called the nurse at home and she said instead of pushing the bolus, she did it as a piggyback, but set it wrong. No adverse effect, a PTT was done and she was actually subtheraputic.
A new nurse had transcribed an order "Lovenox 60mg Q12" But time it daily.... that was for R/O PE. Pt ended up not having a PE, so not harm done....but it was like that for 3 days....
I learned we are all human. We are not human if we don't make mistakes. Think of jobs where people make computer errors. No one crucifies them. My cousin did a whole presentation and deleted it by accident..... Human error. "To Err is human." It is just extra scary when patients lives are at stake.
I started going over everything in my head, triple checking, getting nervous to give a med for while. Then I decided I was making myself crazy. I had nurses double check with me when I felt uncomfortable. We have a good team in our ICU.
Nurses, Doctors, Pharmacists, we are all imperfect. As long as we make honest mistakes, are not negligent, or plain lazy, we are good humans meaning to do well in our profession. As long as we learn from our mistakes adn do things ot make sure it doesn't happen again, we can take comfort int he good nursing care we provide.
- Jan 1, '11 by MomRN0913Oh, and personal, sort of error, but not so much a med error happened to my daughter. My water broke at my 36 week appt on the table at the Dr's office. At that moment i found out I was group B strep pos. I wasn't having contractions yet and was far from home. it was 11 am and my MD told me to get ot he hospital by 4pm if no contraction so i can get my first dose of PenG. (my exhusband wasn't home he was far too, i wanted to wait for him) Long story short, after 24 hours away, I spiked a temp, baby became tachy, I became tachy, even though I was 10Cm, the head wouldn't drop, so I had an emergency C. baby went to the NICU as a precation bc of my temp and the group B strep. i called the NICU in the Am and they said they tried ot feed my daughter but she became apenic. They had to hold off on the bottle feeds. Neonatologist was AWESOME, respecting me as an MICU nurse and a scared new mother. Next day she tells me my daughter's blood cultures were positive, she may have spesis and was going to do an LP the next day. I was so depressed. ( IVF pregnancy, almost lost the baby, high risk the whole time, early delivery, a rough road) Although, while my daughter was on bottle feeds, although she was having the apenic episodes still (but we were learning how to work with them, but man, as an MICU nurse, you see your daughter's sats drop to the 70's and see her brady down to the 80's you freak out!) she looked great! healthy weight, 6lbs, 12 oz at 36 weeks, she was jaundiced, needing the lights, but looked great. My neonatologist came int o my room the next morning and said, from her assessment, she looks good, no fevers, normal WBS count and a negative CRP, which is always positive in the presence of Group B strep. She said before she was going ot tap her, she would draw another set of cultures and another CRP.
Well, what would you know..... the second set was negative. The first one was contaminated. The Neonatologist apologized profusely! I said I understand, it happens. i was truly thankful in all of it, the neonatologist treated the PATIENT and not the cultures and didn't tap my baby unecessarily.
After 8 days in the NICU, she was help up because of jaundice and the apenic episodes while feeding. Actually, they said when she doesn't have a episode in 24 hours, I could take her home. One day my daughter had a nurse and an orientee.The primary nurse told me she unfortunately had an episode. The neonatologist just came in and asked my orientee how my daughter was doing, and she said "fine". The neonatologist said we could take her home after the car seat test. I said "hold on, the nurse told me she had an apenic episode last night" The primary nurse, not the orientee was tending to another baby when she called her over. She told her. My baby stayed. Whens he came home she was on an apnea monitor for 2 months which had false alarms all the time giving me heart attacks. But I checked my daughter first,
Very long story, but I wanted to present the whole picture. Medicine is not a perfect science and nor is it's delivery. it' s how you handle the situations.
- Jan 2, '11 by newrngradQuote from BroadwayRNI think its awesome that your shared! I didnt kudos the *mistake* but the fact that you went through it and survived! lol that sounds like a movie!!! good for you for sharing!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.
- Jan 2, '11 by newrngradQuote from DeadHeadRNsounds like the nurses you work with ate their own young.... at least she was being careful and not just *guessing*... it was a little silly.... but not a med error.... the scary ones run around like everything is fine, and just guess and hope at the things they arent 100 percent about turn out to be correct, instead of being a little *anal* = )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.
- Jan 2, '11 by MomRN0913We have a new grad RN who ran blood in over an hour. Which can be done in trauma patients and severe cases of blood loss. But we deal with so many CHF patients and renal patients.... her defense was "I didn't want to leave anything for the next shift"......
- Jan 3, '11 by newrngradI was still in orientation on a med floor and I started a new IV, and the patients wife was an RN, and I knew it....
started the iv fine, was all happy.....
then my preceptor came in with a very serious attitude and said " our charge nurse went to answer a call light and the patient was wondering why his arm was hurting so bad, and he still had his turniquet (spelling?) on his arm..." and then kinda stared at me....
At that point I was so overwhelmed, so scarred about what people thought about me, that I started to cry.... she tried to be nice to me, and said its very stressfull on this floor, but I could tell she was embarrassed for me!
I went directly in the room and apologized profusely, accepted total responsibly for leaving it on his arm, and made no excuses or blamed it on me being young/new ect... the ONLY thing I said was that I must not have seen the turniquite under the arm of your gown.... but that I should have taken that turni off with in 1 minute....
- Jan 17, '11 by UpinawayRNEver tell a pt she her pregnancy test was positive and get an answer "That's impossible, I had a hystectomy after my last" (we'd been slammed at triage and doing several urines and labs, placing them on the counter..apparently this one had wrong label)...oops! Always make time to label immediately, if not before handing pt her cup! Immediately ran into ED to tell MD what I did before she could tell him the idiot nurse told her she was pregnant.
- Mar 3, '11 by newRN1253Thanks everyone for the great posts-Ive made some errors and I carry the guilt around everyday...kinda makes me dread going to work..Im learning through my mistakes and taking responsibility for them.
Mistakes Ive made-Ive given the wrong PO med, Ive infused and IV pibbyback too quickly because I did not check to see that the tubing was hooked up before the IV pump so the med ran in wide open, Ive hung the wrong PPN bag instead of TPN and recently I inserted an NG tube that could have distrupted a suture line. Ive been a nurse for almost two years and everytime I make a mistake I learn from it and am humbled by it-and Ive learned to not judge others. I wish we had a one time mistake rule-once you make a mistake once you are not allowed to make it again. We need to go to the nursing gods for that one. All I can say is Thank (the true God) God that none of these actions resulted in harm to the patient..THANK YOU THANK YOU THANK YOU. And thanks to everyone for thier honesty-it helps to hear that Im not the only one who makes mistakes.Last edit by newRN1253 on Mar 3, '11 : Reason: Too much info given...thought I should be more generic
- Mar 4, '11 by NewlyGradBSNrecently, I started my first day again. I stopped working and the routine....I lost it. First day mistake.
Second day, I had another one. The AP ordered a cbg for one patient (patient A) which I mistook for his other patient (patient B). I remember hearing the name of the other patient (patient B). So, when I took the CBG of Patient B, the blood sugar was borderline low. The patient has hypothyroidism. When I came back to the station he asked me which patient with I took the CBG from. Then, at that moment, I realize that he wanted me take the CBG of patient A instead of B. But then he wondered, why was it borderline low. I also explained that the whole day, the patient did not eat or drink anything. Patient B had D5NM as his IV. He was suppose to get mad and I was suppose to cry my eyes out. I took a deep breath and I took the CBG of patient A. I was trembling, I was so scared that in my second day I had another mistake. I was so disappointed in myself.
Then came a light. When I came back at the station, I said the CBG of patient A which was above normal, considering his case, it was appropriate. He was still wondering about patient B and why was it low. Then, when I was teary eyed and shaking and defending myself that I really heard the name of Patient B....and I mumbled his room number prior to going to the room so that the Doctor would hear me... I didn't get a reaction from him before going to the room. So, I thought he really meant patient B. Then he said this, you know what, maybe you made that mistake for a reason. His blood sugar is low and it makes me wonder. It shouldn't be borderline low, it should be normal to say the least, considering his IVF. So ok, I'll write the order down, we'll put d5050 in his current IVF and we'll monitor his blood sugar. I really thanked God. I was about to go to the washroom and cry my heart and eyes out. The doctor assured me that, I probably made that mistake because he needed to check that patient's blood sugar also.
I learned a lesson today, it was reinforced actually. I should always ask which patient first prior to going out of the station.