Felt like a complete idiot at work yesterday

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Specializes in LTC.

I go into my patients room and find him to be S.O.B and have anxiety. He is already on 2 liters of 02 via NC as ordered. I tell him to deep breath while I call the doctor. His pulse ox was 85-88. While I'm calling the doctor my supervisor remains with him. So I get an order to increase o2 to 3 liters. I come back to increase the o2. As I trace the o2 tubing I find that the patient was never connected to the o2 concentrator in his room instead he was connected to an EMPTY portable 02 tank which caused him to become hypoxic. I felt sooooo dumb and went through calling the doc for no reason at all.

The patients room was so cluttered and 02 tubing everywhere. Next time I'm going to trace the tubing and make sure he's connected to either the concentrator or a Filled o2 portable. Oh well. Totally felt like an idiot.

:nuke:

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Specializes in Tele, ICU, ED, Nurse Instructor,.

Dont feel like an idiot. Im just glad you went in the room when you did.

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Specializes in Nurse Leader specializing in Labor & Delivery.

I think it happens to the best of us. I bet it's a mistake you'll never make again.

I recently had a case where I was taking care of a woman who was in for induction of labor via IV pitocin. Turns out, after two hours, I discovered that I was pitting the floor.

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Specializes in Emergency Room.

First of all, what was the outcome for the patient? I am guessing that as soon as you discovered the source of the distress, you corrected it and the patient recovered with no lasting adverse effects.

Second of all, what did you learn? You already told us what you learned, and I doubt this would ever happen again with you at the helm.

Feeling like an idiot is not productive. It doesn't help you or your patients. Learn from the situation. Suck it up. Move on. :)

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Specializes in pulm/cardiology pcu, surgical onc.

Don't feel bad, I think we've all been there at least once. I've learned to always check my lines (IV's, drains, sxn connections) especially when taking over pt care.

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Specializes in Trauma Surgical ICU.

We all have moments like that.. You learn by them and that is how we improve :) In NS I hung a piggyback of abx but didnt unclamp it so for the hour the pt only received normal saline..I always check the tubing etc now...

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I came in to answer a call light one time and heard what I thought was a funny sound coming from the O2 tank. I found that the patient was hooked up to a very empty tank. I casually engaged the patient in conversation, then went looking for a replacement tank and found all of the tanks to be just as empty as the first one. Frustrating.

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Our instructor told us a story (that I think will stick w/me for the rest of my life!!!) about a young pt w/a severe asthma attack coming in to the ED. They worked on her for a long time, and no amt of O2 would help -- her pulse ox kept dropping. She ended up passing, and as they were cleaning her up, they realized that the O2 tubing wasn't connected to the wall. :eek: With all the commotion and everything running around, no one noticed it.

Don't beat yourself up over it!!

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Specializes in Home Care.
Learn from the situation. Suck it up. Move on. :)

I have a list of things I've felt dumb about. Sometimes it seems that every shift I add something new the list. Some are things I catch myself and other things are caught by someone else.

I won't make the same mistake again.

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Specializes in Med/Surg.

We have a new thing in my hospital regarding "shared learnings" basically everyone discussing mistakes they've made and what the contributing factors were and how they have changed their practice to prevent future mistakes. Its been a priceless opportunity. Nothing will make something stick in your mind better than a first hand account. I encourage you to learn from this and share with your peers so this can be a learning opportunity for them as well.

I had a similar situation, pt had no urine output for 12 hours, even after numerous boluses. When I came on shift trying to figure out *** was wrong with this patient, I noticed the chart said she had a latex allergy and they had used a latex foley and she had never been bladder scanned. That was the first thing I checked and while it turned out not to be the problem (pt and pts family denied her having a latex allergy) it was definitely a makes you wodner moment.

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Specializes in CVICU.

If it makes you feel any better, I saw an anesthesiologist intubate a patient and he couldn't figure out why his sats sucked after he had him tubed. Well, as it turns out, he forgot to hook the ambu bag up to O2! It happens to the best of us!

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Specializes in Geriatric, Pediatrics.

Better to be safe than sorry...I've felt worse...and it is always great when someone has to point it out..."Well so and so says it is not what you said..." Just better to be safe than sorry, shrug it off...you learned for next time!! Now when you are mentoring someone...u can always tell them so they dont make the same mistake too!! :clown:

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