Nursing errors I learned from...

Nurses General Nursing

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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 we learned from those mistakes?

Let's make this thread a positive one and hopefully we will help each other avoid the same errors in the future....:)

Here's one of many of mine...I will add more as we go:

I got hoodwinked into staying over and doing a double. I was exhausted with a sick baby at home and had not slept well in a week. I was like a zombie making that last med pass at 6 am..and I had 13 patients on medsurg to pass meds to.

Well, we were short (and this was 20 years ago...not much different now is there?) and I was behind so I cut corners...found out later I had completely mixed up two patients' medications.: patient A got patient B's meds and vice versa.

Well, luckily these ladies were astute enough to not take them. I wish they had said something to me at the time, but as I said, I was rushed and behind so I probably didn't give them a chance...just pushed the pills at them and ran off....

My director called me at home later very sternly..to come in for a counseling. I felt awful. The ladies, of course, had spoken directly to my boss about this mistake I had made. No harm done, Thank God, as the patients didn't take those incorrect meds I gave them.

I learned not to let myself get talked into working extra when I know I'm already exhausted. Saying 'No' is the safest thing to do in those circumstances, to avoid potentially serious errors due to exhaustion.. And I also learned never to shortcut the '5 Rights' of medication administration because I am 'running behind.'

Anyone else ready to 'fess up'? :imbar

When I was a nursing student, a Doc wrote an order for "40 Units Insulin." The nurse didn't question it, the pharmacy didn't either & sent up Regular insulin and the day nurse gave it before breakfast was on the floor. I took the woman bkfst. Needless to say, she was almost comatose. I got the charge nurse for the floor, she started a glucose IV and I poured sugar under her tongue. The woman finally aroused, but it was touch & go for awhile. I learned it's better to not give the insulin, check the order and make sure the food is being served before insulin is administered-especially Regular. The new Humalog works even faster than Regular. I have to have the tray in front of the resident before I give it.

We get a lot of patients in for outpatient blood therapy. We transfuse them a couple of units and send them home. The order was for Benadryl 25 mg IVP before the first unit of PRBC's infused. I was in a hurry and didn't double check the order. The pharmacy sent po Benadryl and I gave it. After a few minutes I realized what I had done and called the doctor. He was very nice about it and said the po would probably last longer than the IV. Haven't made that mistake again.

I have also given the wrong meds to two little old ladies. (They all look alike after awhile, don't they?) As soon as the second old lady took the meds I realized what I had done. My heart dropped all the way to my feet. :eek: :eek: The doctors were pretty cool about it, but I was sick for 2 days afterwords.

Another thing I have learned over the years, is SIGN immediately after you give a medication. I was covering some patients for one of my co-workers while she was at lunch. The post-op patient was complaining of severe pain. I checked the MARS and saw that nothing had been given. I got the Demerol that was ordered and went and administered the prescribed dose. Not long after that the patient's nurse came back to the floor. I told her I gave the patient Demerol. She got this blank look on her face and said that she had given the patient some Demerol right before she left for lunch. :eek: :eek: She started getting on my case for giving it, and my response was to sign the stinkin' MARS for crying out loud. I can't read minds!! So, now if one of my co-workers is leaving the floor I always double check with them about meds. If it is not signed off, I page their nurse and ask. BTW, the patient was not harmed. :)

Specializes in RETIRED Cath Lab/Cardiology/Radiology.

OK, 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

Specializes in RETIRED Cath Lab/Cardiology/Radiology.

Oh 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!!

Specializes in RETIRED Cath Lab/Cardiology/Radiology.

.... and what did I learn from the above???? Uh . . . hmmmmmm.m.m.... to do a strip search before I discharge a pt????????!!!!!

I 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!!

Specializes in Med-Surg Nursing.

Yeah, 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!

Right drug

right patient

right dose

right route

Right time!

and the 6th is Right Documentation!

I 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....

l

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... :imbar

If 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!

Specializes in FNP, Peds, Epilepsy, Mgt., Occ. Ed.

Of 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

Sooooo 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.

i 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!

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