Nursing errors I learned from... - page 4
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, '02Occupation: Psych Nursing - Director of Nursing Joined: Nov '01; Posts: 33; Likes: 3I have to agree with some of you. All nurses make mistakes. We're human(or at least most of us are). This is a place where you can help others learn from your mistakes and still remain anonymous from coworkers. We have a couple of nurses at work that wouldn't let off with hounding and ridiculing anyone at work if they knew they had made a med error. I'm sure a lot of us have made errors and never to this day even knew we had made an error. But, like most of you, we all learn VERY WELL when we catch our own and vow not to repeat. I like the 6th Right-Documentation.
Jun 12, '02Occupation: Staff Nurse Specialty: Med-Surg, Long Term Care ; From: US ; Joined: Jan '02; Posts: 1,178; Likes: 21jevans posted:
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!
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.
Jun 12, '02Occupation: Enterprise Application Systems Analyst Specialty: 27 year(s) of experience in Everything except surgery ; Joined: Mar '01; Posts: 5,601; Likes: 174I'm glad you addressed giving meds outside of the 1hr window. Whenever I have had to give a med outside of that window...I document the time given! I then readjust the times, and report to the oncoming nurse the time the med was given...and request the med be adjusted back to the normal times as soon as possible. Many times the med is unable to be given at the scheduled times....such as...missing med....new med or change in order....or just too many pts.
I feel every effort should be made to give the med at the times due....but when all else fails...don't just sign off the right time given...if it was outside of the window. I always come on and check to see if all meds ordered for that pt is available. But many, many times...I have had missing doses...and called pharmacy....only to have to call back several times, or send down a copy of the order to get the med sent up. Especially when you have new pts admitted...or a change in orders! In fact I have had to call for the med...send down the order, and then call again...and have to send down the order a second time! One tech told me...after I stated I had already sent a copy...that if I didn't send another copy...it would take him even longer to send the med, if he had to search for the order sent...
Jun 12, '02Joined: Jan '02; Posts: 5,673; Likes: 159Personally I suspect med errors are kinda like roaches...if you see one there are hundreds you aren't seeing.....
I work with some nurses who are so busy hounding 'the other shift' about their boo boos they don't see the fact that they make many of their own...
You guys are right...many nurses are hard on each other for their imperfections on the job. It's not right, but I see it.
I don't count 'retiming' a late med as an error because this happens so frequently simply due to the slowness of the pharmacy system in the hospitals I've worked at here. Some are worse than others, but one in particular it's not unusual to get a stat med started 4 hours later cuz pharmacy is so slow.....
Jun 12, '02Occupation: research nurse Joined: Oct '01; Posts: 1,878; Likes: 44Oh, I'd never chart an incorrect time for a med. I may be crazy, but I'm not stupid. Or maybe I'm stupid but not crazy, I don't know. It doesn't matter - - I'm one or the other but probably not both.
And NOT every time that I was outside the time window (1/2 hour before and 1/2 hour after - is it the same everywhere?) was because the pharmacy couldn't/didn't deliver the med on time. Sometimes it was early because I was giving the person something else and knew he'd be going somewhere, or maybe I'd been delayed in my first round of meds. Weird stuff happens.
I know some night nurses who have always given the 2000 and the 2200 meds at the same time. When the hospital changed to the policy that the going-off shift wasn't allowed to pull the first set of meds for the next shift, they changed the standard time for BID meds from 0800 and 2000 to 0900 and 2100. I ignored that entirely and stayed at 0800 when it would have given me a pile of patients with meds at 0800, 0900, 1000 etc. because the policy for the Q 6 hr and Q 8 hr meds still started at 0800.
Jun 13, '02Joined: May '02; Posts: 5,114; Likes: 9,366Hung dopamine at mcg/min instead of mcg/kg/min........no wonder his BP wouldn't come up! CCU caught it, pt had no ill effects, and the cardiologist was very gracious about it. When I apoligised and said "well THAT'll never happen again", he said that's all he needed to hear.
Jun 13, '02Joined: Jan '02; Posts: 5,673; Likes: 159I have been pleasantly surprised at the responses of docs to some pretty serious med errors.
It seems their bark is worse than their bite and although they may be BEARS if THEY find the error, they will likely be quite understanding when the nurse catches it and calls to inform him/her.
A nurse coworker switched a patient's meds and caught it. She felt awful and came to me as charge, and I called the doc cuz she was so upset. Well, he was quite understanding. These were major cardiac drugs and resulted in the patient going hypotensive and symptomatic during the night...I had to call him for a fluid bolus...he STILL was nice about it. I was shocked! LOL!!!
Jun 13, '02Joined: May '02; Posts: 979; Likes: 11We had a chronic vent patient come in from a nursing home, and the trach holder was fastened with the old twill ties, instead of the velcro straps we use. I mentioned to another nurse that I hate those ties, since I'm always afraid someone will cut the pilot line when they cut the ties to change them. I decided to just go ahead and change them, so I pulled out my trusty bandage scissors, cut the ties, and cut the pilot line too. I had to call the doctor to come in and insert a new trach tube. Fortunately, he was one of the docs that does not blow his cool about these kinds of things. Every time he saw me for the next month, though, he made scissors motions with his fingers.
Jun 13, '02Joined: Mar '01; Posts: 230; Likes: 4I was a new nurse, on a respiratory floor, we had two patients with the same name, and I of course gave the wrong medication to the wrong patient. I never checked the armband of the patient! I don't know why I didn't check it but, I didn't! I do now, always. I have also hung the wrong bag of IV fluids on a pediatric patient. I work in the ER and I got in the pixis to get the IV fluid out of the NS bin, the bin said normal saline but, the bag was D5NS. I cried and cried. The ER Doc was great about the whole thing, I guess the worst part of the hole ordeal was that I never caught that the bag was not NS the floor caught that it was D5NS and that is why the child had the elevated sugar!! I never got to apoligize to the family, which is something I wish I could have done. Because they were questioning whether this young girl was a diabetic! Always check and re-check!!!
Jun 13, '02Joined: Jan '02; Posts: 5,673; Likes: 159RNinIcu...your post made me laugh! I never shave a patient with an ETT in without wrapping a washcloth around the base of the tube....for the same reason you said....I accidentally cut the line to the balloon once too!
Luckily the respiratory therapist came to my rescue with a 'repair kit', and saved the day.
But I always got ribbed by that therapist then on...he said he always carried a repair kit on him when I was on duty...LOL!:roll
Jun 13, '02Occupation: LVN Joined: Mar '00; Posts: 32; Likes: 1The first time I made an error it involved giving patient A's meds to patient B. I realized my mistake after the fact, and reported it to both the MD, and nursing supervisor. Had to stay over and fill out the incident report - and patient B had to be monitored for any adverse reaction, which fortunately, there were none. I made this error while working my sixth night in a row between two different facilities. Lessons learned: always check the five rights, never work so many shifts in a row again. I'm convinced this mistake was mainly a result of how exhausted I was.
Mattmom81 is so right on about staying alert and not trusting that things have always been done properly before you start. Pharmacy has been known to mislabel medications (for example, I've found lasix in a bag assigned to a patient receiving pepcid - she didn't even have an order for lasix . And recently a patient had someone from the lab come draw his blood without any orders - turned out there was an order for his room mate to be drawn, but he had been discharged the previous day. This wouldn't have happened if the phlebotomist had checked the patient's wrist band.
Jun 14, '02Occupation: RN Joined: Aug '01; Posts: 2,276; Likes: 42I just thought of an error I made about six weeks ago. A patient was admitted from ER with some kind of cardiac problem. I got report from the ER nurse. The patient came up, I assessed him a filled out the paperwork. It was right before the shift change, so I was trying to get out in a hurry. Evidently, the ER was bolusing this man some IV fluids and I never checked the rate of the IV pump against the admission orders. I don't remember ER telling me that he was being bolused (but they might have, I just don't remember). Any way, the nurse who followed me didn't check the rate, and she infused a liter of fluid in an hour or so. The man got into some CHF problems, which he had a history. It improved with Lasix, and I don't think he was seriously harmed. But, I check those pump rates now!
Jun 14, '02Joined: Jan '02; Posts: 5,673; Likes: 159That's a good point, Deespoohbear...your story made me think about the fact that ER has their own med stocks and many times will 'mix their own' IV meds, and/or use a different concentration. They may have different protocols than the units do for these drug mixtures.
It's important to look at the label to see how it's been mixed ie Heparin or Nitroglycerin...it can get confusing. I have caught myself titrating a chest pain patient on a Nitro drip only to realize later I didn't have a 50/250 mix but a 100/250 mix and I was therefore charting the incorrect mcg...we live and learn.
Same with Heparin....I have had trouble reaching the desired parameters for PTT only to finally check the bag and see i was titrating to the wrong mix...ER had mixed a drip with different concentrations!
Sooooo.....always double check ER's (or any other unit for that matter) concentrations in IV mixtures and make sure they are correct for your YOUR policy. And if it's not labeled (I have had this happen frequently...ER gets hectic and they forget to label the bag) DO NOT assume it is the same concentration YOU would hang....check it out.