Mistakes we have made - page 8

by LilpoRN | 45,207 Views | 84 Comments

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... Read More


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    I went into the wrong room and introduced myself as the patient's nurse for the night and did a full assessment and flushed their IV...then when I walked out I realized I was in the wrong room! No wonder why were confused because shortly before their REAL nurse for the night came in and did everything I just did!

    I almost gave the wrong dose of insulin to a patient. CNA told me a blood sugar was 300-something, but REALLY the blood sugar was like 203. She got the results mixed up with another patient. The results are always uploaded into our system from the glucometer once it is "docked" at it's station...so now I know to always recheck the result if I'm not taking the blood sugar myself!

    We had a patient come up from the ER who needed 2 units of blood. 1 unit was already infusing but the ER ran it very slow and it nearly went past the 4-hour mark...oh, and the nurse didn't do any of the hourly vital signs! The patient was okay, thank goodness. I hung the 2nd unit and had it going and then the clerk asked where the consent form was, and I said, "what consent form?" and then I nearly flipped! It was signed in the ER but we didn't have a copy of it. And here I have blood infusing on this patient. ER lost it, but we still needed that consent form in the chart. I got another form signed and explained that it got lost along the way (because it really did) and there were no problems. Now I know to always check the chart for a signed consent form!

    I was pulling out a Norco for a patient. Well I wasn't paying attention and thought I was only supposed to pull out 1 tab, but really I was supposed to pull out 2. I rechecked the order on the MAR after pulling out just one and realized I needed to pull out another one! So I just tried to return it but instead of having me return it to it's respected cubicle, the Pyxis had me return it to "box 39" (the one that can only be opened with a key). Then the Norco was grayed out because it was out of stock...so I got my correct dose from the Pyxis down the hall.
    The next morning my manager calls me telling me there was a "discrepancy" and that I needed to explain what happened. I came in and wrote up my discrepancy report for the pharmacy. She joked and said, "you didn't look high this morning and your pupils weren't pinpoints so I believe you" and I just laughed. I told them I would submit to a drug test right then and there if pharmacy didn't believe me!

    This one happened recently...Patient was post cardiac-cath, had a femoral sheath that needed to be pulled...but 2 vital pieces of information were missing from the report I received from the off-going nurse: 1) the sheath was to be pulled as soon as the patient came to the floor and 2) the patient received no anticoagulation. And cath lab made it confusing by hooking up a bag of heparin to the sheath, even though it wasn't infusing. The nurse said to just pull it when I can...well, I had an admission right at shift change. So I couldn't get to it until around 20:30...I called the cardiologist asking if it was okay, and he said it was (because there was no order of WHEN to pull, even though the cardiologist argued that there was an order...) and then minutes later cath lab call saying the sheath should have been pulled earlier than now, the artery could have clotted off, blah blah blah...I was expecting to get an EARFUL by the cardiologist but he just told me it should have been pulled earlier and him and 2 cath lab techs came up to pull it...no problems. Of course it still falls on me, but I definitely learned after that experience!!! I'm just glad there was no harm done to the patient.
    Last edit by turnforthenurseRN on Apr 23, '12 : Reason: typo
    Gold_SJ likes this.
  2. 0
    Quote from ERnurse2001
    As a student I crushed a K-Dur (potassium) tablet and put it down an NG tube. I didn't realize the K-Dur wouldn't dissolve and it ended up clogging the tube Oh, and this happened in the middle of the night. I dreaded having to call the Dr. in the middle of the night for a new order to re-insert the NG and have to admit my stupid mistake but fortunately (for me) the pt. ended up pulling the tube out shortly afterwards and then I had a legitimate reason to call.

    Another time a nurse told me to give pt. xxxxxx a "20mg Bentyl injection." Well I didn't bother to check the order myself and I ended up giving it IV instead of IM. Bentyl is not indicated for IV use...it can cause a thrombosis and/or embolism when given IV. Had to write that one up and kick myself later.

    I always remind myself that 1) always follow the five rights, 2) you can never get vital signs too often, 3) when in doubt, stop and find out first and 4) know your institution's policies!
    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?
  3. 0
    Quote from Daliadreamer
    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?....
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    Quote from FCMike11
    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.
    Last edit by Gold_SJ on May 20, '12
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    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.
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    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.
    turnforthenurseRN and Gold_SJ like this.
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    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?
  8. 0
    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!
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    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.
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    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.


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