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

I'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.

Mattsmom81

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.

With Respect

j

I'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:

Everything counts!!

Love

Dennie

I 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.

Specializes in Med-Surg, Long Term Care.

jevans 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 have to admit that part of the gut-wrenching, heart-in-the-throat, nauseated reaction I've experienced when discovering a med error is for fear of what may happen to my patient, another large part is directed at my own carelessness, but another part is related to "what will my peers think/say about me?" Who hasn't heard the furtive whispers, seen the frown or the rolled eyes when a co-worker is discussing someone's recent med error? We're hard on ourselves, but we're also hard on each other.

shannonRN posted:

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.

My response to having a support group for med errors is that *ALL* of us should be members. If you think you've never made a med error, I believe there's a great possiblity that you just weren't aware that you've made one. The amazing thing to me is that we don't make MORE med errors when you consider all of the patients with multiple system problems and all the meds they take, the acuity, the short-staffing, the hectic pace...

Specializes in Everything except surgery.

I'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...:(

Personally 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.....

Oh, 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.

Love

Dennie

Specializes in Trauma, Teaching.

Hung 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.

I 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!!! ;)

We 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.

I 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!!!

Y2KRN

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