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 Cath Lab, OR, CPHN/SN, ER.

Also, I am totally appauled at how many people have fessed up to mistakes that weren't reported. I may still be a student, and understand that there is "real world" nursing, but still! :angryfire You know what you did was wrong...own it! Just because your patient didn't crash that minute doens't mean there are not serious consequences down the road. -Andrea

Two things kind of funny from my first GN job in the mid 80s, one not so funny in L&D 10 years later. I was working on a 20 bed oncology floor that also served as an overflow floor as well as the VIP unit(strange bedfellows indeed). We had an addict recovering from an abcess scheduled to leave that morning. Wanted to take a few things out to her car so she wouldn't have so much to carry when she left. I went to ask the other nurse--I still can't believe I was this stupid in 1986--and when I got back, the patient, of course, was gone. Did she come back? Nope!

Another night there were 2 of us GNs on with 1 other nurse. The other GN discovered a tick on one of our old guys thigh--who knows how it got there? She was working really hard on getting it off when I came in and our conversations went something like this:

Me:"Abby?"

Abby:"Hold on, hold on, I think I've got it!"

Me: "Abby, I think he's dead."

Yes, the man who fortunately was a DNR had expired during his tick removal and Abby was so focused on the tick that she didn't noticed he was no longer breathing.

The third was on L/D; the OB ordered an IV pain reliever, I forget which, and after I gave it the patient's contractions stopped almost immediately. I was SURE I'd given her Brethine by mistake and even took all the vials out of the trash, looking to see. Called the doctor, who said not to worry, just wait and see what happens. She started contracting again within an hour and I've never been sure that I didn't push Brethine.

Aneroo, how could you? Give two OTC meds that could hurt very few people without an instructor? Your instructor sounds like a control freak. I don't think any of mine would have gotten so upset about it. If I'd pushed morphine alone, maybe, but not tums.

As far as unreported mistakes . . . well, I've had a few too. When you don't have enough time to care for your patients you hate to take extra to do piles of paperwork. If it's in any way harmful to the patient, of course you report it, but if you gave an antibiotic at 6 instead of 4 because you were crazy busy and lost track, you let it go. It's just triage. Real nursing is different from theoretical nursing.

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

I know that years ago, we had certain meds that had to be double-checked, such as IV Digoxin, Heparin, Insulin, and IV narcotics--can't recall the whole list, but the list hung in the Med Room.

Nowadays, we don't have to check any of them. I personally feel safer getting a check on my cardiac boluses such as Cardizem, heparin, and other cardiac gtts like Dobutamine.

I recently surprised a couple of nurses by asking them to double-check a calculated dose. For instance, if I have to give 0.5 mg of Haldol IV and it comes in a 2 mg/ml vial, I'll have someone double check to make sure I didn't screw up on my math and give the wrong dose.

Although once, I saw two nurses agree on the wrong dosage :uhoh21: ....caught that one before it got to the patient and we all agreed it was an easy mistake to make, so we reported it to Pharmacy and Risk Management as a near-miss.

As a student in clinicals, my friend and I ended up putting hemmroid cream on dentures, unbeknownst to ourselves.

Specializes in OB, M/S, HH, Medical Imaging RN.

I work Med/Surg but yesterday got pulled to CCU. I got a new admit (87 y/o)whose dx was: CHF exacerbation, and bilateral pleural effusions. Really nice man, a walkie/talkie. He had a NGT gtt when he came from the ER at 5cc/hr + NS @ KVO, then the cardiologist came in and added lasix/diurel drip at 10 mg/hr and dobutamine and dopamine at 2mcg per kilo gram which was 10/cc an hour each. The label on the lasix said 10 mg/hr (25cc) which I took to mean 25cc and hour but it was actually 10 cc an hour. He put out 5,000 cc urine in 8 hours. He felt better needless to say. His legs were cramping. I got a stat K and it was 3.5 and I turned the lasix off to talk to the charge nurse. It was then that we realized that it should have been running at 10 cc/hr. Oh I felt soooooo bad. They assured me that my mistake would not in any way hurt the patient, they explained it to me and I completely understand what they are saying but I am so upset about making the mistake in the first place because I am so conscioncess. That's the only fear I have in my job is making med errors. I filled out an SOE because I want to accept full responsibility. I just can't get over feeling so bad about making a mistake that resulted in an overdose. I did learn a lesson. I should of set it at 10 cc an hour and then asked whether the 10 cc/hr or the 25 cc/hr was correctl

It's probably not going to be my worst mistake but I gave "breakthrough pain" oxy instead of routine oxy. There was only one pill left of the routine oxy that I was supposed to give until pharmacy came and someone put it in a little envelope in the narc's box. I, of course, failed to see it. The next day routine oxycodone arrived from the pharmacy and it was erroneously labeled "For breakthrough pain only". It just proves mistakes are made all around. You feel bad but you have to go on and try harder.

I work Med/Surg but yesterday got pulled to CCU. I got a new admit (87 y/o)whose dx was: CHF exacerbation, and bilateral pleural effusions. Really nice man, a walkie/talkie. He had a NGT gtt when he came from the ER at 5cc/hr + NS @ KVO, then the cardiologist came in and added lasix/diurel drip at 10 mg/hr and dobutamine and dopamine at 2mcg per kilo gram which was 10/cc an hour each. The label on the lasix said 10 mg/hr (25cc) which I took to mean 25cc and hour but it was actually 10 cc an hour. He put out 5,000 cc urine in 8 hours. He felt better needless to say. His legs were cramping. I got a stat K and it was 3.5 and I turned the lasix off to talk to the charge nurse. It was then that we realized that it should have been running at 10 cc/hr. Oh I felt soooooo bad. They assured me that my mistake would not in any way hurt the patient, they explained it to me and I completely understand what they are saying but I am so upset about making the mistake in the first place because I am so conscioncess. That's the only fear I have in my job is making med errors. I filled out an SOE because I want to accept full responsibility. I just can't get over feeling so bad about making a mistake that resulted in an overdose. I did learn a lesson. I should of set it at 10 cc an hour and then asked whether the 10 cc/hr or the 25 cc/hr was correctl

I have several mistakes that I always tell the new grads I precept - it takes me off the pedestal and makes me seem human.

The first was when I was several months into a new job/state. It was nights of course I was in charge - I with several months experience total. At the end of report at 11:30 I was called into a patients room. She was in the bathroom, which looked like a blood bomb had gone off. Blood everywhere. I don't know how she did that - the blood was on all 4 walls - waist high. She was covered - the bedroom and bed looked a massacre had taken place. She had had a vag bleed - cervical Ca. At any rate, stat hct, etc etc, endless cleanup, I was to say the least a tad frazzled when I finally had her settled. My next patient called for me and asked for benadryl. She was a sickle cell patient - frequent flyer and the narcs made her itchy. I grabbed the med and gave it to her. This before the days of PYXIS and all the meds were jumbled together in a bin - all their prns etc. As I walking out the door to get something else for her, she sat straight up and started to seize as well as projectile vomit - all the way across the room.

What had I given her? I can tell you there is a difficult to breath feeling as well as that gnawing knowledge that I must have given her something bad. I actually went back into the med room and dug through the garbage - I was sure I hadn't!

Clearly I had. It turned out I had given her compazine instead of benadryl - the containers were the same size and the print on each of them was in black - thus my mistake - I had in my frenzied state from the other patient and her bleed out had not looked closely. Now granted it should not have been in her bin since she had an allergy to it, but it doesn't excuse my not checking closely. She ended up being fine - the hospital paid for her admission and I was forevermore uncomfortable around her. This wasn't my last med error that year though.

The second biggie I did was with a 19 year old with neurofibromatosis (spelling) which had become cancerous - She had a huge inoperable abd tumor that made her look preg. This tumor had also wrapped around her ureters and among many problems she had was enormous pain. She had a forest of IV pumps in her room on both sides of the bed. Several pumps were hooked to the caths keeping her ureters and infused medication - I don't recall the purpose) - she also had antibiotics, IVF, 2 PCA's one with MS one with versed and another pump for her epidural gtt. This was before the days of locked epidural specific pumps. She had come racing back from a procedure and the bag was empty - so I changed it quickly and got her back into bed - an arduous process. Her pain kept increasing all evening.

It wasn't until the next day when I go to work that I was told what I had done...I had hung Vanco instead of whatever it was she had for her epidural - talk about your heart sinking to the floor. It turns out a person can get Vanco into the epidural space, and because the gtt was at a slow rate she didn't exceed the amount allowed. I was her primary nurse so I continued to care for her until her death. I felt pretty bad about contributing to her pain though...

Those two mistakes occurred when I was a newbie and I recognize their value in teaching me to slow down - take the time to look at what you are giving and to remember you are a human and to be thankful when your screwups don't permanently harm someone.

My error has kept me from working since the day it happened. I so terrified that I may make another mistake which may lead to a patients crash or even death. It was a busy day and I was overwhelmed (still no excuse) and my patient was on a sliding scale insulin. I took the blood sugar and she required FIVE (5) UNITS of insulin. to this day I do not know what was going through my mind but I pulled back to FIFTY (50) UNITS instead of the minimal FIVE (5) she needed. I did my checks that it was the proper insulin. I took the patients medication profile to her bedside and compared her armband to the profile and I stated to her that I was there to administer her insulin.

Still not knowing that I had done the error I left the hospital at the end of my shift which was about 45 minutes later. I had helped her with her tray and asked her if there was anything I could do for her before I went off shift. (because sometime report & shift change take a while), she replied no.

I was at dinner with my husband at a resturant and while eating my soup, which was the first part of my meal, IT HIT ME WHAT I HAD DONE! My husband saw my face and asked me what was wrong I immediately grabbed the cell phone and tole my husband to just leave money and drive me to back to the hospital. I called the unit and told them about the error - they said 50!?!?!?!?! I said yes I will be there in 5 minutes. They changed her iv fluid to 50% dextrose and ran it at 100/hr. I stayed with her doing continuous bld sugar tests until midnight. Her BLOOD SUGAR never dropped below 8.1 - in Canada (Ontario) normal blood sugar levels are between 3 and 7.

I was praised and praised for coming back and admitting my mistake. I haven't worked as an RN since.

You guys don't have to double check insulins w/another RN? I know in nursing school we were told that even as RN's we have to double check insulins w/another RN....I think heparin as well?

You should be proud of yourself for coming back and admitting the mistake!!!!!!!!!

As a student in clinicals, my friend and I ended up putting hemmroid cream on dentures, unbeknownst to ourselves.

:roll :roll :roll

funny!

Specializes in OB, M/S, HH, Medical Imaging RN.

In the US we have to have insulin that we pull up double checked by other RN and then signed off. We do the same with IV heparin, IV digoxin, and IV lopressor.

In the US we have to have insulin that we pull up double checked by other RN and then signed off. We do the same with IV heparin, IV digoxin, and IV lopressor.

We were taught "Did I Kill Him" to remember the names of the medications which have the greatest potential for harm if given incorrectly:

D : digoxin

I : insulin

K : postassium

H : heparin

NurseFirst

+ Add a Comment