Your Worst Mistake - page 18

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,... Read More

  1. by   mstigerlily
    So far my mistakes have not yet been serious, I know I will have one though, everyone does. Just the other day I was to give 140 mg IV of a steroid to a post op pt. This steroid was to cover her does for the day since she couldn't take her po meds (she was on high doses of steroids). Well this pt was ill and nauseous so there were many IV pushes to give until I found the right combination and when the steroid was due I brought it in and gave it. The pt was finally asleep after vomiting/being in pain so I didn't announce what I was giving and what it was for like I normally do.

    Two hours later she was awake and asking for more nausea medication. She casually mentioned perhaps she was nauseous because of "all those pills she took"!!! I asked her which ones and she rattled off her list of daily meds her partner had helpfully brought from home - including the steroids. It's terrible having to tell your charge nurse and the pt you made an error and to write up an incident report but luckily pt was very understanding. I will never again give a med without reiterating what I am giving or discussing it with pt ahead of time!!!

    Quote from mwcia12
    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.
  2. by   elizabells
    I caught holy heck today for letting my knee touch the floor when I crouched down to do, um, something I don't actually understand to a PEG tube. Thread it through the pump, I think? Anyway, the RN made me go home at lunch and change my pants because my knee touched the floor.
  3. by   jeepgirl
    Quote from elizabells
    I caught holy heck today for letting my knee touch the floor when I crouched down to do, um, something I don't actually understand to a PEG tube. Thread it through the pump, I think? Anyway, the RN made me go home at lunch and change my pants because my knee touched the floor.
    Uh oh. In peds, I do that on a daily basis! I try not to rub my knees against my patients tho. Hospital floors are dirty... but it is hard when you are unsteady like me!
  4. by   nicuRN2007
    Quote from poopsiebear
    My worst mistake ...

    I work in the OR and occasionally, our patients have local anesthesia for their procedures. I made the mistake of not posting the "Patient is awake" sign on the door while the patient is having a bilateral orchiectomy. One of my friends came to my room to say hi. She looked around to see what case I was doing. Then all of a sudden, she blurted out, "Is it OK for men to live without their balls???" The room got deadly silent and after I whispered to my friend that my patient is awake, she quickly slipped out of the OR.

    I know this is old, but I just read it and all I can say is HOLY CRAP!!! :stone
  5. by   epiphany
    It's been said before, but as new grad, it's so important to hear these things, so thank you all for sharing. It has certainly opened my eyes, knowing it can easily happen to me. Seems like there are 2 kinds of nurses: one who has made an error and one who will. (shudder)
  6. by   jhowirn
    Once upon a time, in the icu, I was taking care of a patient who was receiving iv fluids and Diprivan. Sometime, during the night, I went in to hang a dose of iv antibiotic, which I piggybacked into the iv fluids. I dialed the amount and rate of the antibiotic, pushed the start button, and left the room. About 10 minutes later, I looked up at the monitor which informed me that the arterial line bp reading was like, in the 70's/30's. Not good. I ran into the room assessed my patient and the situation. The source of the low bp quickly revealed itself. I had dialed the rate of administration for the antibiotic into the channel that was running the Diprivan!!!! I wanted to vomit, I was so horrified at what I had done. Fortunately, the problem was easily reversed by turning off the Diprivan, and within 30 minutes, the patient's bp was fine. Lesson learned: to this day I don't run Diprivan and fluids on the same pump!
  7. by   jhowirn
    Quote from estrogen
    Don't they have ambu bags in nursing homes? I'm about to transition from med-surg to a nursing home and once I'm there, if they don't have an ambu bag, I'll personally go to a med supply store and buy one. :angryfire
    Get a pocket sized face shield. I have one and it never leaves my side. Just in case.
  8. by   jhowirn
    Quote from redwinggirlie
    Letting family stay on the floor afer hours.
    Big no.

    LOL! Thanks redwinggirlie. We need this touch of humor after sharing our mistakes with each other.
  9. by   sirI
    Quote from nurse1975_25
    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.

    Believe me I can relate: I, too made a near fatal med error. Fresh out of school and the nurse in charge of the Labor and Delivery Unit (3 - 11) and gynecological surgery floor. I had 5 OB's (no excuse) and had to go to the floor to evaluate an elderly lady who was 2 days post op and vomiting. Hardly any output, too. The physician came up and ordered 10 mg. Urecholine STAT. The LPN asked how she should give it. I thought, hmm, since she is not able to tolerate oral fluids, give it IM. In the mean time, went back to OB. The med was sent up by pharmacy (without a sleeve on the amp). The LPN gave it as I instructed. Almost immediately, the lady starting profuse diaphoresis and drooling. The LPN called me back to evaluate. The lady was most hypotensive within 5 minutes. Started all the correct measures in a case such as this and notified nursing service. The supervisor came up and we looked up the drug and saw where closed cardiac massage should be prepared. The pharmacy was contacted. The drug should NOT be give IM. Only SQ or orally. The physician was notified. He came and looked at the lady and left. I stayed by her side hours after the incident. Measuring B/P, output, etc. Ready for her arrest. She did not and acutally improved in about 2 hours. Needless to say, I was written up for this. To this day I will never forget what I did. Many errors were made in this instance. The drug should have been ordered SQ or orally. The drug should never had been sent up in an amp without the route specified. The drug should have arrived from the pharmacy with the warning sleeve: for SQ use only. The LPN should have known to give it orally or SQ. I should have know to give it correctly as well. But, I was ultimately responsible. I almost quit, too.

    I wish you had not quit. I wish you would go back. Mistakes happen and I believe due to your instance, you would be hypervigilant and NEVER do that again. You learn from these things. Please reconsider, unless to much time has lapsed for you to do so. Just know that sharing this with everyone takes alot of intestinal fortitude on your part and you should be commended.

    It is a scary thing knowing the extreme responsibility we have over people's lives. It is a wonder many of us stay within this profession.

    I did go on and became a Nurse Practitioner and before that, taught practitcal nursing. I tried to prepare my students and keep them from making the BIG one. But, ultimately, they go out on their own and learn for themselves.

    Thanks for letting me share this with you. I know it was long.
  10. by   Audreyfay
    Quote from gwenith
    I still think one of the classic mistakes of all time was the poor yound student nurse who decided to clean everyone's teeth so, in the interests of efficiency she collected all the false teeth and stuck them in the steam sterilizer - now comes to redistribution................... Took a dentist 6 months to sort the mess out.

    My most favorite story of all! :chuckle
  11. by   elizabells
    Quote from jeepgirl
    Uh oh. In peds, I do that on a daily basis! I try not to rub my knees against my patients tho. Hospital floors are dirty... but it is hard when you are unsteady like me!
    lol - my first thought was "well, I'll do my best not to knee the patient in the trach" but then I would have been a snotty BSN student so I just smiled and nodded and did as I was told...
  12. by   JVanRN
    Well mine isn't a horrible mistake but it's pretty darn embarassing. We had gotten a bad baby and the doctor was going to put in UAC/UVC lines. Well I pulled out the set up for a chest tube (just the sterile setup not the drainage thing) opened it up and layed out all the other equiptment for a UAC/UVC placement on a sterile chest tube tray.

    When the doctor turned around to get her equiptment she asked "who set this up?" I was like "uh something wrong?" I thought maybe I forgot a syringe or got the wrong size gloves. No I had half the set up wrong. Luckily this doctor is cool, she just got another one set up. If it would have been the other doctor he would have made a HUGE fuss out of it and made an example for the whole unit to laugh about. I was mainly embarrased because I have set these up about a million times...I just kind of automatically do it. I guess next time I need to READ the package before I open it.
  13. by   JVanRN
    Oh here's one that really had me worried though. I had gotten pulled down to adult ICU. I had a man that was getting Lopressor IVP for high BP's (I can't remember the specific parameter the doc ordered right now) The nurse told me she had last given it about 4 hours ago. Well when I assessed him I looked on the monitor and his BP read 188/102. The BP monitors are USUALLY set to take BP's q15 minutes unless changed. (No this is no excuse....I'm not trying to excuse my self really) Well I see that and decide to give him his lopressor...started pushing it then check his BP 84/39. ***** I didn't push it that fast....why is is BP dropping so low? Dropping some more 79/40. I'm about to crap my pants at this point. I just kept taking it praying it would come up and fast. After about 15 minutes it started to slowly creep back up.

    My dumb butt looked back at the 188/102 BP and realized that was a BP from THREE HOURS BEFORE. It had apparently come down since then but I didn't check. The monitor was not set to check BP's every so often. I guess the nurse changed the settings. I was just assuming that was a current BP. It was not. So I basically gave him Lopressor for a probably normal or even low BP because I didn't bother to check first.

    No when I work in ICU or anywhere my patients are hooked up to a monitor I check the parameters...I also check BP or vitals that need to be checked right before I give a med...I don't rely on VS that are hours old or what the monitor says when I walk into the room.