Mistakes we have made

[LilpoRN]

I think it would be beneficial to us all to share stories of mistakes we have personally made, or almost made, or stories we have heard or seen of other nurses making mistakes. I don't know about all of you, but I know I learn best from mistakes. Something about that scare tactic drills the lesson in a little deeper than if someone was just to say "next time you should do it this way". I'm a brand new RN so fortunately I personally don't have any stories, but I have heard some good ones from experieneced RN's. I am off orientation in two weeks, so since I've been an RN I've always had someone double checking everything. I did have one close one though.

Our patient was taken to OR right before shift change. He was also a new admit from ER for Auto ped accident. In report we heard his lactate was high and his blood pressure was on the soft side. They had tried getting access but he was a hard stick, they even used the site rite ultra sound machine to try to get a peripheral and had no luck. He had one IV the paramedics had managed to get. His electrolytes were also thrown off. Phos was low, K was a little low, and he was going to need calcium. So we knew he was going to need some fluid resusitation and more than one IV for access. Anesthesia had said they would put a central line in our patient while he was in OR.

Patient is in OR and I started pondering the idea of what if he comes back really sick from OR. I asked my preceptor and the other nurses in our pod what they would do if he comes back unstable.Say they get the central line in but no chest x-ray had been done yet to verify. We know he is a hard stick, say our efforst are just as bad. Would they go ahead and use the central line before verification? Everyone agreed, if he was unstable enough YES they would use the central line.

Patient comes back from OR, Line is in, vital signs appear stable and he still has vecuronium on board so he isn't moving anything. I look at his central line to transduce a CVP from and there is a wierd dead ender on it, my preceptor recognized it to be the hub of the wire they had totally forgotten to pull out and she took it out. A fair amount of blood came out but we didn't think too much of it, we hooked up the CVP and a huge wave form appeard. It was definitely an arterial wave form. Chest x-ray by this time had been up and gotten verification of placement. It was in the CAROTID ARTERY! The doctors immediately came to bedside to pull it out and the patient fortunately didn't stroke from it and ended up being fine, but it was scary to think we had all talked about transfusing something through that line if need be. To think if we had given anything through there it would have gone straight to his brain.

Lesson for me learned is never trust any line placement until it at least has been transduced. But ALWAYS get chest x-ray first.

Your turn to share

[FCMike11, BSN]

Great thread--

My first ever med error was when I was working in LTC. We had handwritten MARS (AWFUL- you think MD handwriting is bad?). My patient was getting po lasix, which I only noticed she was getting once a day. I worked the day shift. It was halfway through the month, and I realized that I had missed her 1400 dose every day that I had worked. I only realized it after I saw another nurse's signature by that particular time, on my days off. To my defense though, the 1400 was handwritten and squished under the 0900 line and could barely be seen. The nurse that had handwritten this particular MAR was the nurse that had worked on my days off and knew her own handwriting.

I transcribed a medication wrong from the hospital orders to the LTC MAR

When I was brand new to a hospital setting, I had never wasted anything before, had never seen it done. I guess on my orientation I never had to waste anything. I went home with 1mg dilaudid in my pocket. The next day one of my patients was in pain and the pyxis was occupied, so I just used the extra dilaudid from the day before. WOW, I know. I cried for several days. Luckily my co-workers were really supportive.

I've run antibiotics at a slower rate than prescribed

I have given IV bendryl 25mg instead of 6.25

I've probably done other errors without realizing, like most of us have

You didnt really cry for days right?....

[Gold_SJ]

You called a doctor for an order to reinsert an NG tube? Do you call a doctor every time an IV goes bad for an order to put another one in?

In many facilities it is policy to ring the doctor for a new insertion of a NG tube. Is in my facility. It's not for a new IV insertion but the private hospital next door to our Public one it is policy to ring and ask. Depends on the hospital.

You didnt really cry for days right?....

And that comment has no basis to the discussion. How people deal emotionally with a mistake is completely varied. This thread is to have fun and share, to learn from one another not to pick apart how one responded. In my opinion anyway.

XD Anyway sharing mistakes...hm when I was in my postgrad working on our Medical/surgical floor, I have no idea why, but I completely missed a woman's insulin. I realised four hours later when going to give her lunch insulin. I just stared at it then horrifyingly had to go tell the Co-ordinator and Dr. The resident was 'Why? Whyyy?' He was as stressed as I was, I could only tell him I have no idea, I've never missed a drug before, I gave her everything else. So he had to ring the surgeon to tell him. She was fine but I'd put the poor resident in hot water. Could only apologise and then self report on our Prime system. Bleh was far more anal over medications from then on.

[Lynx25, LPN]

First day in LTC- first day as a nurse.

I pulled out my meds with my preceptor (Right meds! Right Dose!) Double checked everything extra closely (Right time!)... first day ya know- I haven't figured out that I need roller skates to get everything done in time with 30 people. Now, we don't use bracelets or any ID here- because it is a "home", so I asked someone to "Point out Ms XXX, please, I'm new!". The aide happily pointed to one of 15 or so LOLs sitting up at the dining room, and I fed her the pills... (Right route! I'm awesome!)

My preceptor came around the corner, and asked how it went, and pointed... to someone else. (OH GOD WRONG PATIENT!!) Turns out it was the LOL sitting beside the one that was pointed out to me, they were both in matching gerichairs, both tiny with white hair, and both snuggled up in matching blankets.

So... I got to fill out my first incident report. Nice. No harm done.

Absolutely a learning experience.

[dirtyhippiegirl, BSN, RN]

I missed an abnormal EKG on a new admit. He had a change in LOC which caused another EKG which was the same but still abnormal. We ended up doing cardiac markers, etc. His heart issues were old, old, old. But I was still written up -- rightly so, I could have ******' killed someone.

[tn nurse]

Well, on to making errors with medications. Has anyone here lost their job of being a nurse, well, I am fairly new nurse, grad in august 2011. I made 2 errors over the past months and now I can lose my job. I love my job and am careful, I made a mistake and now if I have any other med errors I am fired! Thats it, don't they realize this is a nursing job and I am being careful, I felt worse than my employer knows and I still am worried that I could lose my job I love.

What to do? Be perfect at everything or just keep beating myself up over this?

[Morainey, BSN, RN]

My latest bonehead mistake was not putting in an admission order (in addition to the diet, activity, meds, etc on an ER admit). Sometimes admitting or the physician enters that particular order, so I go out of the habit of checking it. Sigh. You can bet I'll always check it now!

[Buffy31]

I really biffed it today. I'm in my last quarter of nursing school & have tried to be zoo careful about checking stuff before I do things. I was working with a nurse on the renal floor & I flushed 5ml NS into what I thought was a Central line, which it is, but it was for dialysis..CRAP! The nurse was right at the bedside too, and I thought she was listening to me talk about how different the ends look from other lines--has a dead-ender instead of a MAP...I should've listened to the little voice in my head saying "hey, don't flush that", but I didn't. I got 5ml in when the nurse said "that's a dialysis line!" and ran out. I knew right then I biffed it so I put new dead enders on & waited for her to return. She came back with a mask on, withdrew blood & reloaded the one flushed port with heparin. Her concern was that I didn't have a mask on. I had to tell my instructor & she was not too upset, because I fessed up right away & she stated that it will be a learning experience as I will remember this forever. The nurse had to fill out an incident report & the other nurses stared telling me stories about their mess-ups...I know the biggest risk is infection, but I was treating it like a central line without a mask.

Sigh.

[OnlybyHisgraceRN, ASN, RN]

I was working on a TCU unit that was always crazy busy. Often, I would start my med pass early so that I wouldn't be behind. One day I gave coumadin a half hour before it was due. After I administered the coumadin, the NP came to me and stated she just rec'd the residents' labs and wanted to change the dose starting today with repeat labs in two days.

I told the NP I already administered the warfarin and it was too late to start the new dose. She said " you gave it this early"? I was embarrassed. My NM was right there listening to the whole convo ( thank goodness). NP had to rewrite all the orders, thankfully no harm was done. From then on I always made sure to check to see if labs were done before administering warfarin.

[Double-Helix, BSN, RN]

1. In the mornings, I always make a brain sheet for my patients, including the meds they are due for at each hour of the day. My patient was due for Flagyl at 8 am. He also had about 8 other meds due at that time. On my peds unit, the practice is for the pharmacy to stock the medication in the med room. Depending on the medication, it can either be in the Pyxis, in the patient's non-refridgerated bin, or in the refrigerator. We get single doses of IV medications, but multi-dose bottles of PO medications. I was gathering his medications and took the bottle of PO Flagyl from the fridge- correctly labeled with the patient's name and the dose that was on my brain sheet. I gave the PO Flagyl with the rest of the medications and then went to sign the MAR. The MAR said the patient was to get IV Flagyl. The PO Flagyl had been discontinued a couple of days before, but no one had removed the PO medication from the fridge. Now I make sure to double check the route before I give a medication if I know it has PO and IV routes, and I always return the discontinued medications to the pharmacy right away.

2. Not on my unit, but on our general peds floor... A patient was supposed to get IV Keppra. Got IV vecuronium instead. Stopped breathing (that's what vecuronium dose), a code was called, patient was intubated, rushed to ICU and worked up for the code. About 30 minutes later someone brought us the empty syringe and we all realized the patient wasn't breathing because the poor kid was medically paralyzed. Wrong med, wrong dose, wrong patient. We all check our medications a little more carefully now.

[tcvnurse, BSN, RN]

I have been a nurse for ten years and this near miss scared the you-know-what out of me. I was preparing meds at the nurses station for one of my patients. He was s/p CABG and was also a diabetic. I had the insulin syringe and tuberculin syringe (what we give heparin with) and the vials all out on the counter.

I started drawing up the heparin. When I put the vial down, I realized I'd just drawn up a whole syringe full of insulin into the tuberculin syringe.

After I took a few deep breaths, I chucked everything in the sharps box and started from the top, this time with ONE vial and ONE syringe at a time.

I tell everyone I precept about that near miss, hoping it will prevent a tragedy. Because if I could do it, anyone could.

[LarryCarter]

I work on a Inpatient Rehab floor so we normally do not get many psych patients. We had one a while back though that had been hit by a car and needed the services of intense inpatient rehab. The patient went through several psychotic episodes during her stay so we were ready with the Haldol should she need it. I had her one night and she started to have an episode. I immediately called the pharmacy to get a STAT dose sent up, which they did. I read the order as 6mg every 6 hours, but the dose was actually 2 mg every 6 hours. I pulled it up and gave the Haldol without scanning it and realized my mistake soon after. The patient was ok, restful, but ok. I make sure to scan all meds now even if it is an emergency situation.

[Hay Nars, RN]

1. missing an order for iv fluids on a patient who attempted sucide by ingesting whatever pills he could find. :-/

2. removing cbi 1 day early (didn't see the order said d/c saturday) on a 18 year old walkie-talkie female. --who was discharged later that day.