What's the biggest mistake you've ever made as a nurse? What did you learn from it?

[Mini-Murse]

If you feel comfortable posting to this thread, awesome. If not, no biggy!

I was wondering what the biggest mistake you've ever made in your nursing career has been. It could have to do with drug dosage or administration, or forgetting something, or even something as simple and innocuous as saying something to a patient or colleague before you could stop yourself!

The reason I think this thread is a good idea is that it shows that we're all human, we all make mistakes, and it will help us learn fro each other's mistakes, especially me and my fellow students, and ease our nerves a bit, so we know that we're not the first to ever take 15 tries to lay a central line or need 5 minutes to adjust an IV drop, but instead we're just part of a larger community who's support we can count on!

To be fair, I'll start.

I was working in a pharmacy, and a patient was prescribed 2.5mg Warfarin. I prepped the script properly, and accidentally pulled a bottle of Warfarin 5mg. I counted out the proper amount of pills, and bottled em up, passed it to my pharmacist for verification. She verified as accurate, and we sold the medicine to the patient. The patient's wife called a few days later and talked to the pharmacist who verified (who was also the pharmacy manager), and we discovered the mix-up. Luckily he hadn't taken for very long, but it terrified me. I could've been responsible for someone dying because I didn't double and triple check the meds. I got reprimanded, and she pharmacist got nothing. (this was also the same pharmacist who misplaced a full bottle of CII meds for 48 hours - she found it behind some loose papers on her desk)

I learned that there is no detail too little to double/triple check in medicine. I learned that it's never acceptable to "get in the zone" and work on reflex, and that every action you take has consequences; some more deadly than others.

[sharpeimom]

Calinurse,

If it makes you feel less panicky and scared about your daughter's egg allergy, I was allergic or intolerant to

so many foods as a baby, that I was tested early. I repeatedly tested positive for an egg allergy (and still do!)

so my mom didn't give them to me in any shape or form.

When I was about three and a half, the babysitter fell through and my uncle and his brand new wife volunteered to keep me overnight and bring me back in the morning. They, together, knew virtually nothing

about little kids and somehow, my egg allergy was forgotten.

We had scrambled eggs and pancakes for breakfast and I mentioned later how good breakfast had been, to my

mom. When she called the pedi, she said either it was a very very mild allergy or a false positive.

Decades later, I still test positive to eggs, but eat them with no problems whatever. I'm not trying to give medical advice. I'm just saying don't give up hope, since she didn't react to the shot.

[becca001]

My biggest mistake was a med errror on a pediatric pt. I had recently been transferred to the ED after working for a couple of years on a stepdown unit and while the rest of the hospital uses metric system, the ED uses standard. Still being in the mindset of my former unit, I thought the triage nurse meant 20 kilos and did the mental conversion in my mind from kilos to pounds and entered the information. So when I admitted the pt, I started her antibiotics right before she was to go to the floor. Unfortunately, the pharmacy was dosing her at 44lbs and this wasn't caught until the pt arrived on Pediatrics. Thank goodness for pediatric nurses. The antibiotics were not enough to hurt the pt but the potential for damage is there. Now I double and triple check everything on peds patients.

[ashleyisawesome, BSN, RN]

im still on orientation on a med/surg unit. just a couple days ago, i went into a pts room to put up a new bag of fluids. she was sleeping, so i didnt want to wake her and look at her IV site, so i just quietly hung the new bag and walked out. i even charted that her IV site was wnl, dressing dry and intact. an hour later she rings her bell and says her arm hurts and its all wet. The site was infiltrated. it was so swollen and red, i felt so bad. it didnt seem to bother her that much, she said she thought it was kind of interesting. hah. i pulled her IV, elevated her arm and had another nurse start a new one (because i havent started an IV yet and I didnt want to cause the poor girl any more pain via me attempting to wiggle a sharp needle into her arm not knowing what i was doing.) ive learned assessing IV sites is pretty important from now on!

[aachavez]

You're a new nurse and have never done an IV stick? That scares me a little bit... I'm in my RN program now and would be terrified if I found out we wont get some exposure to that! Then again, maybe I won't? Has this happened to many others?

[LindaB73]

You're a new nurse and have never done an IV stick? That scares me a little bit... I'm in my RN program now and would be terrified if I found out we wont get some exposure to that! Then again, maybe I won't? Has this happened to many others?

Most programs do not teach this anymore. Something they say you will either learn on the job or have an IV team to do. We learned it in my program but only got to practice on a fake arm.

[cn2007rn]

This was a few years ago and it was a paper MAR, they had the Lantus and regular insulin listed right in a row and I got mixed up, no policy that I know of but I left that hospital. The hospital that I worked at more recently does have high alert meds highlighted and some of those meds needed 2 nurses to sign off so it could be give.

[cn2007rn]

Just wondering if your facility has a policy that insulin and other high alert meds have to be verified by 2 nurses? I had a near miss with insulin one time. It was night shift and I was going to give sliding scale insulin based on the day time scale. When checking it with another nurse it was brought to my attention that the pt was not suppose to get any insulin based on the night sliding scale. Mistakes are so easy to make. I usually triple check my meds but somehow in this case I was reading the MAR wrong, didn't scroll down far enough to see that there was another sliding scale below the daytime one.

I just posted a response to this above, sorry!

[Nursetastic]

I accidentally attached Pitocin instead of LR directly to the hub of a triple codon and opened it wide; the lines were clearly labeled, I was just chatting with mom and not paying attention. The patient may have gotten, at max, 2 cc's before I caught the mistake. The patient had a 10 minute tetanic contraction. I put mom on a mask and stayed at bedside. Thankfully the baby's heart rate stayed stable and mom was ok. I explained exactly what happened and mom revealed she is a RN in a neighboring city. She and I ended up turning it into a learning opportunity. She was amazing but I still have not recovered! The midwife, unit director, and charge nurse were all amazing actually. My mistake caused a change in line label sizes and colors to draw more attention to high risk drugs.

[tiredRNstudent]

You're a new nurse and have never done an IV stick? That scares me a little bit... I'm in my RN program now and would be terrified if I found out we wont get some exposure to that! Then again, maybe I won't? Has this happened to many others?

I just found out that we are not allowed to start an IV at any of our clinical sites (I think because of insurance reasons). We do have to know the mechanisms of how to do it, but the only practice we get is in lab next week on a fake arm that bleeds. I think it's a little crazy that we won't be able to start on IV on a real person until we are licensed RNs.

[PediLove2147, BSN, RN]

I made two med errors, neither too damaging. I gave full 25mg tab of Metoprolol instead of half 12.5mg tab. I also gave Ativan instead of Oxycodone. Both patients were fine, just a little sleepy for the second.

We did not do IV starts in school. I learned as part of a program in my hospital. We also do not do double checks for insulin (except IV) although we do them for other high-alert meds.

[RNJill]

For some reason this one really sticks out in my mind (although I know that I've made others)!...

My patient needed lab work and was an extremely difficult stick-we could only use her feet and they had already been stuck multiple times (some had been unsuccessful). As fate would have it, she was a post-op patient and had rapidly started to go downhill. Around the time that this was happening, the charge nurse was able to draw her blood. I was so shaken by the patient's status change and rattled from a nasty debate with the resident about whether the patient's condition was as serious as I believed it was that I sent ALL FOUR TUBES OF BLOOD to lab UNLABELED!! Argggghhhh!

Of course this meant that the lab couldn't take them and the stat blood work that was instantly ordered (when the ATTENDING finally convinced the resident that the case needed attention) couldn't just be added on to previously sent blood. I was sooo embarrassed to have to spill the beans to the patient and the charge nurse (who was awesome enough to miraculously draw more blood for me!) - not to mention give the MD a heads up about why the labs wouldn't be available as soon as they thought they would be.

Sooo, I learned to ALWAYS label your blood/reqs correctly and follow the same routine with them EVERY TIME!

[HippyDippyLPN]

On my first job as a nurse in LTC I had a 30 pts on a sunday and was doing a discharge. I correctly wrote the meds, dosages, and directions on the discharge sheet and double checked it was correct. We sent pt's home with 3 days meds in freaking labled ziploc baggies. well of course we were 3 short so my manager told me to double up on the meds to each bag and put two labels on the bag. I put lasix and another medication in the bag. The one med was 4x/day and the lasix was only one. But I labled them both as 4x/day. So the pt took 4 lasix the next day because he was going off the baggies instead of the discharge papers and he ended up in the ER. He was fine thank the lord! But I was terrified and felt sick for doing harm to this pt. I learned to triple check everything and not to listen to that manager who had me double up on bags. I felt nervous doing it and I learned to go with my intuition. I was wrote up and put on a probation of sorts for 30 days which I completed fine but I left shortly after.