Your Worst Mistake

Nurses General Nursing

Published

Here's mine:

I was working a night shift, which to this day I truly detest. When I got report, I found I had a patient in acute alcohol withdrawal (which in and of itself makes me furious, because there is no excuse for a hospitalized patient to suffer DT's if someone knows what they're doing, but I digress.)

Anyway, back to this unfortunate soul.

Because he was delusional and combative, he was restrained so he couldn't yank his IV out for the 10th time. They had also wrapped his IV site with kerlex as an added precaution...maybe if he couldn't find it he'd leave it alone. He was also being transfused with a couple of units of blood.

When I got there, he was nearly through the first unit, and I was to finish that and hang the next one. Well and good. Or so I thought. I started the second unit, but I had one hell of a time infusing it. I literally forced it in with the help of a pressure bag, and I am not kidding when I say it took a good 6 hours to get that blood in. Meanwhile, the patient was getting more and more agitated, which I attributed to his withdrawal.

Finally, mercifully, the blood was in so I opened up the saline to flush the line. But it wouldn't run. All of a sudden I realized, with absolute horror, what had happened.

I cut off the kerlex covering the IV site hoping against hope I was wrong, but alas, I wasn't. Yes indeed, I had infiltrated a unit of blood. I hadn't even bothered to check the site.

No wonder he was so agitated, it probably hurt like hell.

An hour later my manager showed up, and I told her what happened. She was probably the most easy going person I've ever known, and she told me not to worry about it.

I said "Listen to me, I infused an entire unit into his arm, go look at it." She did, and came out and told me to go home. I expected consequences, but never heard another word about it. But I am here to tell you I learned from that mistake.

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.
Not criticizing anybody, but aren't nurses taught in nursing school anymore to double check heparin and insulin with another RN while drawing it up? That's what I was taught, both as a hospital corpsman in the aNavy 30 years ago, and when I went to nursing school (i graduated in '81.) I still do it to this day--always, always, always--check my insulin and heparin with another RN, or a surgeon, or an anesthesiologist as I draw it up. We verify what the label says together, and what's drawn up in the syringe. The more I read, I am fearful that this simple technique is not being taught anymore.

To be honest with you, I wasn't taught that in school, and I'm not a new nurse. (Of course we checked and doubled checked all meds with our insturctor.) So for a while I wasn't checking insulin with anyone until I read it was policy after noticing a few people come to me to double check. They usually come with the needle and not the order, the accucheck or a copy of the med sheet. And no double-signing of the med sheets. But still this helps with big orders because if someone comes with 40 units of Regular a big red flag would come up.

But surely you've been around long enough to know that what you're taught in nursing school and the real world isn't always true. :)

But surely you've been around long enough to know that what you're taught in nursing school and the real world isn't always true. :)

Of course--but Heparin and Insulin errors are the most preventable of errors, if only one would take the time to double check with another nurse. With Insulin, it isn't just dosage--it's TYPE of insulin.

And with Heparin--well, there have been many preventable intracranial bleeds that occurred (and sometimes caused death) because somebody drew up and administered Heparin from what they THOUGHT was a multidose 1,000 Unit per cc vial--when, if they'd double checked the vial with someone, they would have realized that it was a 10,000 Unit per cc vial--or, even worse, a 30,000 Unit per cc vial. The vials are even COLOR CODED to prevent these errors--but, when people are in a rush and don't double check, they happen. I know, because as a legal nurse consultant I've reviewed cases like these, and I've also read about them in my own local newspaper. Such a preventable tragedy.

They like to call this a "systems error" and blame it on the manufacturers, but, in reality, just reading the label and simple double checking, as we were taught to do in the '70s and '80s, (as were nurses before that era) could have prevented it. So, this is one thing that I still do, exactly as I was taught long ago. I think, though I cannot say for certain, that most RNs who trained in the '70s and '80s still do it this way. I know the OR nurses I work with do.

But surely you've been around long enough to know that what you're taught in nursing school and the real world isn't always true. :)

Of course--but Heparin and Insulin errors are the most preventable of errors, if only one would take the time to double check with another nurse. With Insulin, it isn't just dosage--it's TYPE of insulin.

And with Heparin--well, there have been many preventable intracranial bleeds that occurred (and sometimes caused death) because somebody drew up and administered Heparin from what they THOUGHT was a multidose 1,000 Unit per cc vial--when, if they'd double checked the vial with someone, they would have realized that it was a 10,000 Unit per cc vial--or, even worse, a 30,000 Unit per cc vial. The vials are even COLOR CODED to prevent these errors--but, when people are in a rush and don't double check, they happen. I know, because as a legal nurse consultant I've reviewed cases like these, and I've also read about them in my own local newspaper. Such a preventable tragedy.

They like to call this a "systems error" and blame it on the manufacturers, but, in reality, just reading the label and simple double checking, as we were taught to do in the '70s and '80s, (as were nurses before that era) could have prevented it. So, this is one thing that I still do, exactly as I was taught long ago. I think, though I cannot say for certain, that most RNs who trained in the '70s and '80s still do it this way. I know the OR nurses I work with do.

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

The longer I'm a nurse the more paranoid I become. I'm not the cocky new grad I once was. The other day I had a vial of Digoxin that had .5 mg/cc. I went to a nurse and said "I'm to give .250 mg, which means 1/2 cc........am I right?". I'm that way with a lot of things no matter how simple the adminstration seems, Heparin and Insulin included.

We had a rash of pharmacy errors a couple of years ago when we would order stroke Heparin protocols and they would prent up a medical heparin protocol and the nurses were following the wrong sliding scale for days. One can't always trust their med sheets either.

It's an awesome responsibility. :)

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

The longer I'm a nurse the more paranoid I become. I'm not the cocky new grad I once was. The other day I had a vial of Digoxin that had .5 mg/cc. I went to a nurse and said "I'm to give .250 mg, which means 1/2 cc........am I right?". I'm that way with a lot of things no matter how simple the adminstration seems, Heparin and Insulin included.

We had a rash of pharmacy errors a couple of years ago when we would order stroke Heparin protocols and they would prent up a medical heparin protocol and the nurses were following the wrong sliding scale for days. One can't always trust their med sheets either.

It's an awesome responsibility. :)

Specializes in Renal, Haemo and Peritoneal.
Is it always the nurse's fault when an IV infiltrates? I am a student, and just two weeks ago I was giving an antibiotic IV to a guy, my instructor was right there with me. I flushed it with saline first, which went in fine, so I started the IV and went to get the linen to change his bed with. I came back, and it had infiltrated. I shut the pump off immediately and called the IV team. About 15 cc had gone in. I didn't think this was my fault, but now after reading your posts, I am not sure.

Don't beat yourself about the head about this one! It was just bad luck and as you are new you are hypersensitive to events of this kind.

Specializes in Renal, Haemo and Peritoneal.
Is it always the nurse's fault when an IV infiltrates? I am a student, and just two weeks ago I was giving an antibiotic IV to a guy, my instructor was right there with me. I flushed it with saline first, which went in fine, so I started the IV and went to get the linen to change his bed with. I came back, and it had infiltrated. I shut the pump off immediately and called the IV team. About 15 cc had gone in. I didn't think this was my fault, but now after reading your posts, I am not sure.

Don't beat yourself about the head about this one! It was just bad luck and as you are new you are hypersensitive to events of this kind.

Specializes in Renal, Haemo and Peritoneal.
Well, with everyone admitting their errors, here's my worst error:

Fresh out of school in 1984, as a GN, working night shift with 15 pts (me and an aide), I had to flush all the saline locks. Back then we had boxes of hep lock flush, potassium, and benadryl on top of our med carts. Each box held about 24 sindgle doses of each med. I used to come in an draw up all my flushes to give during my first rounds..... Well I guess you can figure this out by now:crying2: :uhoh3:

As the shift ended, I realized that I had a full box of hep lock flush and I had flushed everyone with Benadryl!

:imbar

Well, everyone got a good night sleep that night anyway! I still get goosebumps thinking about that!

So glad that they have done away with that system.

thankfully you didn't flush everyone with potassium!

Specializes in Renal, Haemo and Peritoneal.
Well, with everyone admitting their errors, here's my worst error:

Fresh out of school in 1984, as a GN, working night shift with 15 pts (me and an aide), I had to flush all the saline locks. Back then we had boxes of hep lock flush, potassium, and benadryl on top of our med carts. Each box held about 24 sindgle doses of each med. I used to come in an draw up all my flushes to give during my first rounds..... Well I guess you can figure this out by now:crying2: :uhoh3:

As the shift ended, I realized that I had a full box of hep lock flush and I had flushed everyone with Benadryl!

:imbar

Well, everyone got a good night sleep that night anyway! I still get goosebumps thinking about that!

So glad that they have done away with that system.

thankfully you didn't flush everyone with potassium!

Specializes in Renal, Haemo and Peritoneal.

after veiwing a lot of the post on this thread it makes me wonder why some of the drug errors happened. In Oz we always get an IV, IM or subcut drug checked by either an RN or drug endorsed EN. Many RN's choose to get oral drugs like prednisone or warfarin checked too (though there is no legal requirment). The checker then takes on a responsibility in that they are deemed to have given the drug too. The checker, of course, signs the medicaton sheet too.

In the USA is it common practice for RN's to doublecheck injectable medications and sign for them or does it not occur?

Specializes in Renal, Haemo and Peritoneal.

after veiwing a lot of the post on this thread it makes me wonder why some of the drug errors happened. In Oz we always get an IV, IM or subcut drug checked by either an RN or drug endorsed EN. Many RN's choose to get oral drugs like prednisone or warfarin checked too (though there is no legal requirment). The checker then takes on a responsibility in that they are deemed to have given the drug too. The checker, of course, signs the medicaton sheet too.

In the USA is it common practice for RN's to doublecheck injectable medications and sign for them or does it not occur?

Specializes in CCU, SICU, CVSICU, Precepting & Teaching.

Worst mistake I ever made was hanging heparin instead of Lidocaine. The patient was on both meds, and the bags were all near their 24 hour expiration. When I respiked the bags, I hung heparin on the lidocaine tubing and vice versa. Then the ectopy increased (duh!) so we turned up the "lidocaine." Then turned it up some more. Then went to another drug. I never caught my own mistake -- when I came back in the next morning, the night nurse told me he had caught it when the patient started peeing red. Uh-oh. I always follow my tubings from the patient to the pump to the bag now. Every time I hang a bag, every time I assess a patient.

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