Scariest thing you have found - page 4

What is the scariest thing that you have stumbled across after following someone else? I found that a Dopamine drip had been started and left on all weekend on my medical floor that had staffing... Read More

  1. by   kids
    I was working in a sub-acute facility...came to back to work after 4 days off to find a patient with frank blood in his foley bag...thick frank blood. Patient A&OX4, states has been like that since he stepped on his tubing 3 days ago. I checked the chart...every day for the past 3 days the SAME nurse documented that he had BRB per foley in the SAME note she documented giving him 5mg of COUMADIN.

    This was not a case of being stretched too thin or being floated to an unfamiliar unit. The team was 9 patients (stable long-term trachs/vents) with 2 NACs and an RT. The nurse (happened to be an LPN) had been on the unit with (most of) the same patients for 2 years. She had no IVs (facility wouldn't even let LPNs assess a site or hang a fresh bag of maintenance fluids) and the RT did everything that involved the respiratory system-from inhalers to trach care. It was the one and only nursing job I have ever had where I got all of my work done and got to leave on time every day.

    The patient went to the hospital. It took a week (and a Urologist) to get the bleeding controlled and to pump enough blood in to him to send him back.

    I got written up for chewing her out.
    Last edit by kids on Jun 1, '03
  2. by   Good_Queen_Bess
    A long time ago, I heard a story of someone putting LACTULOSE down someones central line instead of the NG tube. YUK! Sticky veins!!!
  3. by   gwenith
    NG down an IV has happened over here to a neonate. This is why a lot of NG tubign is made ot be incompatable with IV ends. Scariest thing I evers saw - gods I've seen my fair share form the patient connected to teh respiratory circuit that did not have expiratory line to the incorrect admixture of drugs.

    Possibley one of the more "infamous" cases that occured here in Australia happened in NSW a few years back - new RN little clinical experience sent as agency to ICU. ICU EXTREMELY busy so accepted untrained staff. He gave oral Phenytoin IV ! Checked the dose with another nurse but of course she did not see him give it. PT died BIG inquest - outcoem not only was the nurse investicated but the other ICU staff on that night, the agency employing him and HIS UNIVERSITY LECTURERS WERE PUT ON THE STAND!!!!
  4. by   Liddle Noodnik
    Originally posted by moonshadeau
    And I do want to add that we all try to be the best that we can.
    When I oriented for my new job recently, they showed a movie about hospital errors. It was supposed to be the prelude to a discussion about "no blame" for medical errors. But what it did was have half a dozen nurses sobbing. It showed how pressured we really are (showed it REALLY well, so well that it could be any one of the places I'd worked in 23 years). The purpose of the class was errors but I felt like a raw open wound afterward; we could really KILL someone by our screwups! And whose fault? Not ours!

    It showed a pregnant woman and her husband, both from Russia and almost unable to speak English, and she was having grave symptoms (major bleeding, major pain, etc.) and she kept getting passed from nurse to nurse to nurse and no one was calling the doctor even tho she was begging.

    Then the surgeon started cutting even before the intubation was complete (for a c section). AND, the baby was given a wrong med. Both of them died. Talk about OVERKILL.

    I wish there had followed a discussion of how to change the system instead of about medical errors/incident reports. they told us the purpose of the incident reports WAS to change the system, but I can't see that happening anytime soon.

    I also thought it showed how much we need to join together, work together, speak up together, support each other as in support groups, etc.

    The movie was MAJOR heartbreaking, and here you all are talking about similar things.

    That movie made me want to quit, just like a thousand "nights from hell" have in the past. In fact I "retired" from nursing 3 times (the first time at 26 years old!) because of stuff like this.
  5. by   Liddle Noodnik
    Originally posted by kids-r-fun
    I got written up for chewing her out.
    See, there is rule number one of nursing: Don't be human and react. You must at all times be stoic and accepting that things are the way they are.
  6. by   Jay-Jay
    The patient went to the hospital. It took a week (and a Urologist) to get the bleeding controlled and to pump enough blood in to him to send him back.

    I got written up for chewing her out.

    Now, that IS scary!!

    BTW, yes, 2/3 and 1/3 is the percentage of NS to glucose in the IV bag.
  7. by   Coldfoot
    The worst things I have seen........
    Ok, the scariest this is walking into an ER Room and finding dirty "Mystery" sharps. Who knows where they came from, who left them there, or how long they have been there?

    Had a Surgical resident atempt a chest tube on a stable, concious spontaniouse pneumo without any PN control (he was stopped as soon as ER Staff walked into the room).

    Working as a paramedic, responded to "siezures" non-emergent and found pt in Status SZ's UNDER THE BED!!!!!!!! in an LTC. (Pt was s/p unwittnessed fall.)

    Transported out of LTC after new RN gave D50 IM (She musta worked at pushing those 25cc's in)

    There are some scarry people out there
    Last edit by Coldfoot on Jun 1, '03
  8. by   Hellllllo Nurse
    Oder incorrectly transcribed as :

    1000mg Vit K, IM qd X (I forget how many days)..
    Even worse, although there is no such order, and the Vit K comes in 10mg/ml ampules, several nurses had signed this out as given.

    I can imagine a "nurse" drawing up amp after amp into the worlds largest syringe, trying to get the "1000 mg" dose.

    The order was supposed to be for B-12.

    I did find amps of Vit K in the cart w/ several doses missing.

    Pt turned out to be ok, because no one had actually given the pt anything, just signed that they did. Adm covered it all up, anyway.
    they "lost" the incident report I filled out.
  9. by   Hellllllo Nurse
    Originally posted by zoeboboey
    Yes, I am aware of that, but still don't know what 2/3 and 1/3 is. Is that the percentage of sodium?
    Same here. I know you hang blood w/ NS. But what are 2/3 and 1/3?

    Are they hypotonic salines?
  10. by   Rocknurse
    Just the other week I took over from a nurse (in ICU), and the patient had a temperature of 103. When I look I discover that he had 2 blankets on which I remove. When I pull them back I discover an aluminum space blanket underneath!!!

    I attend report of a young patient who had had a diabetic ketoacidosis coma in ICU. It was handed over that she was on an SIMV rate of 10, but when I check it is set at 0.5 and the patient is tachypnoeic and diaphoretic, and very symptomatic. The nurse was a new nurse who had not been properly trained or supervised. I filled in an incident form for that one.

    On the orthopedic ward, the ward manager forced a patient who had had a total knee replacement (uncemented) to get out of bed and walk. The poor woman was crying in pain, and the manager told her if she didn't walk to the table, she would make her sit on a commode in the middle of the unit and make her eat her dinner there. As she got back into bed a cracking noise was heard, and she fractured her new prosthesis. There was an official complaint, but as usual the manager got off. She placed blame on a student nurse who was innocent. I hated that woman.
  11. by   Rocknurse
    May I add, that if you are worried about making a mistake then make sure you check everything thoroughly. It may sound obvious but a good place to start is right there at hand over report. Check all your infusions at start of shift...rate, content and site. That way if someone else has made a mistake you have discovered it early. Imagine discovering someone elses mistake 5 hours into your shift! Try explaning that one away! Check your emergency equipment, and always double check your drugs. Never rush and always think before you do anything.

    Just recently I thought I had checked an ambu bag at start of shift. I checked the O2 worked and I checked the bag inflated, but we had a code and then I discovered that someone had flipped the connector back to front and it would not fit on the ET tube. I'll never do that again! Have faith in yourself and your own abilities and never attempt to do anything you are not familiar with. It's always better to ask.
  12. by   happystudent
    Originally posted by LilgirlRN
    This happened to my son.. he's in Florida with my mom and my nephew when he was 18. Open tib/fib fx, worst xrays I've seen and I work the ED. Talk to the ER nurse in Florida at the county hospital they took him to because he didn't have his insurance card on him. She assured me that the orthopod was 'the best". They took him to surgery, he was just coming back to his room when we arrived. I asked to see the post op films, they were no different than the pre-op!! Took him home the next day and went to see a real orthopod, had to wait 5 days for surgery to put a titanium rod in his leg because it was infected. All they did in "surgery" in Florida was swab the thing out with betadine and put a posterior splint on!!!
  13. by   Hellllllo Nurse
    Originally posted by hoolahan
    At line change, the nurse hung two dopamine drips instead of the dopa and dobutamine. The drips were double concentrated because the pt had renal insuff. So the dopa was supposed to be like 2.5cc/hr or 2 mcg/kg/min and the dobut was running at 10 mcg/kg/min. So when she hung the dopa instead of the dobutamine, the pt became very tachy at change of shift. She was calling doc and they were initiating bolus of cardizem and she was readying a drip when I discovered what she had done.

    The kick in the butt was, the pt son was there, and he was praising her up and down to me about how she had picked up on her father's change in condition and acted so quickly on his behalf, he was so impressed w the care his father got. Ha!!

    This man was a dean of a lg university, and he offered her a BSN education for no cost!! Do you believe she had the audacity to accept it???? I would have been so embarrassed, I could never in good conscience have accepted that knowing that my error could have killed the man!!! Some people have no shame!!
    Didn't you report it? Could you have written an anonymous letter to the family telling them the cause of the pt's problem?
    This situation blows me away