Nursing errors I learned from... - page 3
OK, to offset the thread "What was the most incompetent thing you ever saw a coworker do" I will start this thread. How many out there are brave enough to admit to mistakes they have made, and what... Read More
Jun 12, '02Joined: Apr '02; Posts: 31,895; Likes: 20,716OK, I'll go:
In my first year of nursing, oriented to SICU (25+ years ago), all I remember is VERY sick pt (dying, really - I would recognize it now, didn't then), RUSHING to try to take care of all aspects of care, time to give heparin, hurried to draw it up and give it .... gave it IM!!! When I realized what I'd done, the Charge Nurse said, "He's dying anyway, I don't think it will make any difference, just don't do it again." I felt so LOW!! Learned, as others have posted: DON'T RUSH, CHECK EVERYTHING TWICE!!
About a year later, taking care of pts in a DOU, interpreted an order for IV Dig for a new-onset atrial fib, I believe. Gave the dose, then somehow realized the cardiologist meant for it to be given in DIVIDED doses, that would equal what I had just given in a bolus!! When I phoned him and reported what had happened, his comment was, "Sometimes the nurses do things the docs wish they had the guts to do," and didn't say another thing about it (guy was on tele anyway).
Another: As a student I was doing newborn nursery rotation. Had a baby in arms, settled in a rocking chair, giving water po (was a bili baby, I think, getting extra hydration between feedings). I let my mind wander and gazed around the room a little, and when I looked down the nipple had slid from the pt's mouth to by his nose, a little water had pooled by the nose, obscuring the nares. I pulled the bottle away, stared at him: was he breathing or not??? I carried him into the main room, a senior nurse took one look at him and exclaimed, "Oh my goodness, that baby is BLUE!!! She grabbed him from me and I watched helplessly as she jiggled him, ran some O2 near his nose and tried to stimulate him. He came 'round right away. I have NEVER forgotten that scene and still kick myself and say: PAY ATTENTION TO WHAT YOU'RE DOING!!!
I'm sure there have been more -- just gimme time . . .
Keep this ol'dog larnin' new tricks! --- Diana
Jun 12, '02Joined: Apr '02; Posts: 31,895; Likes: 20,716Oh yeah - sent a pt home one time, forgot to DC his HL. Seems he got dressed in long-sleeved shirt that hid it -- out of sight, out of mind!!! I called the doc and he had him go to the clinic to have the HL dc'd. Did I feel like a DOPE!!
Jun 12, '02Joined: Apr '02; Posts: 31,895; Likes: 20,716.... and what did I learn from the above???? Uh . . . hmmmmmm.m.m.... to do a strip search before I discharge a pt????????!!!!!
Jun 12, '02Occupation: RN Joined: Aug '01; Posts: 2,276; Likes: 42I have sent a patient home with a saline lock, too!! Makes you feel real good when the patient calls back and says "Hey, how long am I suppose to keep this thing in my hand (or arm)." Uh-Oh!!
Jun 12, '02Joined: Mar '01; Posts: 2,730; Likes: 602Yeah, I think that I've sent a pt home without removing their IV. Man was in such a he11fired hurry to get out the door that he had his clothes on before I got back to read him his d/c instructions. I've had pt's leave before I gave them their d/c instructions because they wanted out so bad!
I think that all of us nurses have made a med error at one time or another. If you say you haven't then you are lying. Luckily for me my med errors have been minor.
When I worked in LTC, was working the acute unit with another RN. Pt was ordered lanoxicaps at 6pm, I gave the pt the dose and pushed it out from the wrong day--happened all the time at this home--pushing meds out of the blister pack under the wrong day. Anyhow, when I gave this resident the drug, the other RN was at lunch. She came back, I went to lunch. When I returned she said to me, I gave Mrs. So and so her dig for you, I saw that you forgot! I was like, I gave her the dig, I just pushed it out of the pack from the wrong day! THe other RN was like well why didn't you tell me! I said if you questioned or not whether I gave it, you should have came into the lunch room and asked me, it's only a few steps away! She ended up being charged with the med error and not me.
Always remember the five rights!
and the 6th is Right Documentation!
Jun 12, '02Joined: Jan '02; Posts: 5,673; Likes: 159I guess we shouldn't laugh, but it's true...we pretty much have to do one last 'head to toe exam' before we let 'em go home ('strip search'...hehe) in order to not leave saline wells , etc in..I have had them call me at home about EKG stickies and nitropastes too....the poor patient thought they were something important he might have to bring back to us! LOL! A few have even got out of here with the tele module in their shirt pocket...hehe.
I am careful to not accept responsibility from the monitor tech if I've got other things going on, and to be assertive with other employees who want to take a break at a bad time...especially if they try to run off quickly. This is why:
I was taking report on a patient in ER when my monitor tech abrubtly said "Time for break" and just ran down the stairs before I could say a word....
Well, I soon heard the major monitor alarm go off and looked over to see an AGONAL rhythm! This patient did not make it, she was too far gone.... and as I looked back in the memory there were many changes the monitor tech had not caught over the last several hours, finally leading to agonal (dying heart) rhythm...
Now in retrospect, I believe she finally recognized what she had when it was too late, and ran away to avoid dealing with it.
Now, when ICU coworkers are in a rush to leave and I'm not ready to assume their duties, I say so. I also take a moment to assess the big picture, ask a few questions, eyeball their patients ( and eyeball the monitors if its the monitor tech on PCU.)
Anyone else had coworkers run off to break only to have their patient code? I have several times, and now I no longer enable that kind of behavior....we all must be accountable, it makes us all better nurses.
Another error I made: We have two docs with the same name...one is renal the other pulmonary....and when the attending told me to consult "Dr. Jones" I figgered he wanted the pulm because the patient was a known COPD.....well, you can guess what happened....he came in, wrote orders, and the attending scratches his head and says, "Well, Dr, thank you for the assistance...now can you help me with his azotemia?" That became a running joke with the "Jones'".
The old joke about never ASS- uming... :imbarLast edit by mattsmom81 on Jun 12, '02
Jun 12, '02Occupation: RN Joined: Aug '01; Posts: 2,276; Likes: 42If one of my co-workers leaves the floor with their pt crashing (and knows the pt is crashing) I promptly page their butts back to the floor STAT. This has happened once or twice and after the crisis I tell the nurse that if she ever does that to me again we will have major problems. I have had a couple crashes and the pt "appeared" fine before break and none of us knew that the pt was going down the tubes. You know, people always crash at meal time and shift change!
Jun 12, '02Occupation: FNP Specialty: FNP, peds, epilepsy, mgt., occ. med., ed ; Joined: Mar '02; Posts: 1,821; Likes: 1,563Of course I've made some errors in 19 years. Med to wrong patient (fortunately Carafate), wrong rate on an IV (misread the pump), and using someone else's calculation on a drug dosage rather than redoing it myself (she was wrong!). I don't think I've ever repeated a mistake twice!
Learned: don't rush, don't get distracted,double check, recheck, and check again. And, as someone else said, LISTEN to that nagging little voice (or that twisty feeling in your gut) because if you don't you'll regret it! Susan
Jun 12, '02Joined: Jan '02; Posts: 5,673; Likes: 159Sooooo true about not letting yourself being rushed particularly with medication administration.....this is where we are likely to make errors due to inattention and rushing!
Trouble is, we are almost ALWAYS rushed because we are so short staffed these days...it seems a fairly universal state of nursing affairs. No wonder our new grads are so overwhelmed....we have so very little precious time to do so many important nursing duties.... soooooo easy to make errors.
I hope students and new grads are reading these posts and the one from Feb...I must have missed that one...thanks RN-PA!!.
One of the reason we must document med errors is because FINALLY med errors are being looked at as a 'systems problem' rather than just a nursing error. Many meds are packaged similarly, or placed within the same pyxis bins, increasing the liklihood of errors.
Jun 12, '02Occupation: onc/heme rn Joined: Oct '01; Posts: 523; Likes: 37i think that there should be a support group for all of us nurses who make errors. you know, kinda of like an aa?! hi my name is shannon and i have made med errors. in my hospital our mars can be confusing....kcl 10meq 1 po #3 qd. well, sometimes i am so rushed that i can miss the x3. when i am charting my meds in the computer at night, i usually catch the error and can give the patient the extra 2 pills. our pharmacy sometimes sends the meds up in the bags with a sticker that says check dose! many times my coworkers take them out of the bags, i say leave them in!!! once we had an order for dilantin 300mg (i think) but they came in 100mg....thankfully i didn't let myself become rushed and was able to figure it out. i think it might have made the situation easier if the pills were still in the bags with the check dose sticker on them. as for the right time....i think every nurse has made an error here. i know that i am not always able to pass all of my meds in that hour window, especially on really hectic nights.
great thread mattsmom....i hope we can all learn from one another's experiences!
Jun 12, '02Joined: ; Posts: n/aI'm so glad this thread was started; what we share can only benefit us, and our patients. One of my mistakes came from two things: not recognizing my own weakness and getting too big a head!
I was working critical care at night and woke up during the day with one of those vomiting "bug of the week" things-you know, where you feel like your navel is hitting your spinal column as you hug the toilet for moral support? Well, I debated back and forth ("I feel better now...oops, just threw up again...) until it was too late to call in to work. And besides: a weak crew was on tonight, I knew they had a full house, and they... (pause for dramatic organ music) NEED ME!!! As I was driving in with a barf bag at the ready, I hoped for a quiet night.
Naturally it didn't turn out that way. I walked in to hear, "Oh, thank heavens, they're swanning the fresh code in 10, can you go help?" Let me tell you that assisting with a swan insertion while vomiting into the trash can at the bedside does NOT endear you to your medical colleagues. The comments ran from a polite, "Jeannie, what's WRONG with you tonight?" to "You idiot, why didn't you call in?" And having the house officer scramble to find 11th hour coverage when agency nurses had been cancelled didn't endear me to management either. When I finally went home, shame-faced, a couple of hours later, I recognized that no matter how inexpendable you like to think you are, the world will turn just fine without you. :spin:
Jun 12, '02Occupation: Deputy Ward Manager Joined: Apr '02; Posts: 523; Likes: 7Mattsmom81
I don't think that we as nurses minimise our mistakes, in fact I think most of us agonise over them.
However we are afraid of judgement, we know when we have made a mistake, acknowledge it to the right authorities BUT afraid that if we admit it out loud to others they will think less of us!
This thread is positive and has the aim of sharing knowledge. We as nurses should supoprt one another in the aim of improving care so please all you out there who haven't replied do so.
Jun 12, '02Occupation: research nurse Joined: Oct '01; Posts: 1,878; Likes: 44I've made a LOT of med errors, if you count not getting them in during the window of time. Oh well.... Nope, I haven't learned a durn thing from them.
I learned a LOT from a med error that happened when I was in school. Another student mis-read the labeling on a MS bag for PCA, the instructor checked it and ok'd it, they hung it and gave that guy 10X the morphine he'd been ordered. It turned out fine for him, the hospital ended up having a nurse spend the night 1:1 with him rather than send him to a unit where wifey couldn't stay with him (he was dying). What I learned: If I had made that mistake, I would have gone down the back stairs, out the back door, into my car and NEVER come back. Never. Never tried to be a nurse. It was very difficult for me to remain in my seat when I even *heard* about this!
So - on to MY experiences! When I was still a student, I gave a guy his 1800 lasix at 1600, having already given him some at 1400.
I learned THE MOST from an ALMOST med error. At this hospital, we had printed out MAR's. When giving insulin, you did the glucose test, and wrote the results. Then you drew up the insulin, and took the MAR, the syringe and the vial to another nurse to double-check for us. The other nurse didn't initial or anything, just looked it over and said okay.
I was to be giving 40 Units of NPH insulin. I drew up the Regular!! That's a LOT of regular insulin! I took the syringe, the vial and the MAR to the other nurse - "yep, 40 units NPH - 40 units - okay." and I walked back down the hall toward my unsuspecting patient. Then I looked at the syringe and I thought "BlooDEE HE11, that's a LOT of insulin" and rechecked the whole thing.
Scared the heck out of me.
Yeah, we're all human, and we all make mistakes. We just have to check and check and recheck and recheck. It's not like we're accidentally giving somebody a large order of fries instead of a regular. That's the thing about nursing: