Clinical Mistakes

Okami_CCRN, BSN, RN · Sep 15, 2014

It was not a mistake but more of a good thing I double checked.

I had a patient on an oncology floor who was on various abx and IVF. The main IVF was bicarb and I had to administer an abx. I went into the room and was ready to hang my abx when I stopped and said let me check IV compatibility. Of course it was not compatible and I had to start a new primary line of NS for the infusion duration. No error was made but I learned that I will always check my IV compatibilities. Imagine if it would have crystallized in the TLC. *shivers*

sjalv · Sep 15, 2014

Not really a mistake but a "duh" moment. Today my patient had been prescribed Rocephin IV. I hung the bag and went to start it only for the pump to give me an error message: "Distal Occlusion; IV stopped". I thought maybe there WAS an occlusion somewhere in the line, so I went to flush it. As I went to flush the line, I noticed I had never unclamped the tubing in the first place, which is why I had gotten an error message :drowning:

vintage_RN, BSN, RN · Sep 15, 2014

Hmm let's see....during my pre grad on a surgical floor I got really overwhelmed one day and I guess I forgot to give my patient scheduled lantus. I couldn't figure out why her sugar was so high and had the docs involved and everything. In the MAR it said beside the lantus "see diabetic profile" so it wasn't signed right there so I must have meant to go back to it but got caught up in other things and forgot about it. Turns out I had missed it the day before too. Always super careful to check over my MARs now. The unfortunate thing was that I had a really great relationship with my preceptor and she always praised me...I considered her a great mentor and we worked really well together. After this error, she didn't trust me anymore and said I shouldn't be working on a surgical floor. She also wouldn't give me a reference for my job and told my new grad preceptor to watch out for me....even though I had taken initiate and done learning plans about the incident. that hurt really bad. It was a low blow for sure. Thankfully to say I now work on a surgical floor and have no issues....we all make mistakes sometimes.

Other than that just stuff like hanging meds and forgetting to unclamp the line. And forcing an NG flush too hard and having it spray in my face.

Bedside_Life RN · Sep 16, 2014

During orientation, the NA came to me, horrified, and reported a HR of 240's during morning vitals. This patient was not on tele, so I asked them to get a manual b/p and apical pulse. As I was rushing to the patient's room looking through meds and calling the attending, asking for the nurse educator to grab the crash cart, I was informed by the attending that the patient had Parkinson's and the HR reported had come from the pulse ox on the patient's shaking hand. Luckily, nothing other than my pride was hurt.

I tucked my my tail and moved on. I will never forget it.