Your Worst Mistake

Nurses General Nursing

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You are reading page 21 of Your Worst Mistake

jhowirn

36 Posts

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.

Editorial Team / Admin

sirI, MSN, APRN, NP

17 Articles; 44,729 Posts

Specializes in Education, FP, LNC, Forensics, ED, OB.
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.

Audreyfay

754 Posts

Specializes in Everything but psych!.
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

Specializes in NICU.
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...

JVanRN

406 Posts

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 me...is 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.

JVanRN

406 Posts

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. WTF? 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.

Specializes in MED/SURG, ONCOLOGY, PEDIATRICS, ER.
The unit I work on is a oncology unit, although we also get medical pts as well. We had a new RN that had been pulled from another floor on night shift, and she was assigned a pt who had been on our floor 2 days. This pt was in for etoh abuse, and had been going through DT's, and was recieving ativan iv. He had not slept for days. The nurse also had a ca pt who was receiving dilaudid for pain control. She had drawn up in two syringes the ativan and dilaudid to save time, and gave the dilaudid to the etoh pt by mistake. The pt went out, but was breathing. All night the pt slept, and the nurse didn't take vitals or disturb the pt because the charge nurse on nights told her to not disturb him since he had not slept in days. The new rn had tried to wake him, but he would not wake up. When The narcotic count was being done, it was discovered that the nurse had given the wrong med to the wrong pt. Still no one checked on this pt. When we got out of report for day shift, I went in to assess this pt and I could not wake him up, not knowing what had happened on night shift because it was not passed on in report and the night nurses had already left, The pt sat was in the 50's, and had probably been there for a long time. The New rn, and the assistant nurse manager both lost their license. The pt is a vegtable still in our hospital, not on our floor of course.:crying2:

:o Ohhhh my God, what a nightmare!! :stone

chadash

1,429 Posts

Specializes in Nursing assistant.
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.

I am so sad you left nursing! How long ago was this?

jhowirn

36 Posts

....& my second worst mistake was accepting a position from my now former employer. Don't guess it would be very professional of me to mention the name of this facility? Anyhoo, to touch up the resume....

LoriAlabamaRN

955 Posts

My worst (only) med error was when I was a couple of months out of school. I was so careful all the time (I thought). One night I was taking the orders off of a chart and I misread one. The order was for Desyrel and I read Seroquel. The physician's writing was very messy, but that didn't excuse the error. When I found out the next day, I will never forget the feeling, like being stabbed through the heart with an icepick. I was terrified that I had hurt the patient somehow. Luckily, he didn't have any lasting effects. It turns out they had tried him on Seroquel a few months prior but DC'd it because it made him too lethargic for therapy. Other than him being very drowsy (and napping in his room rather than going to therapy) there was no harm done. I will never forget that fear, though. I pray that I never make another med error.

Lori

LoriAlabamaRN

955 Posts

When I was just starting as a graduate RN, I had a charge nurse who acted like I was a brand-new nursing student or something, constantly making sure I knew what I was doing. And I don't mean in a preceptorlike way, I mean in a way that was pretty insulting ("You DO know that the insulin you're about to give is to be given sub-Q, right?" "You DO know you can't inject air into the IV when doing a flush, right?"). This went on for over a week, even though I had not made any mistakes and had not given any reason for such poor confidence in my nursing abilities. One night I decided to tease her- I had a patient who got Tylenol elixir because of trouble swallowing pills, and I went to give it one night ("You DO know that since the elixir is 250mg/cc then to give 500mg you give 2ccs, right?"). When I came back she said "Everything go alright?" I said, perfectly straightfaced, "Yes, he said he didn't like the taste so I gave it IV, that's ok, right?" OH the look on her face- priceless. When I laughed and assured her that I was teasing, she laughed her head off and said that she knew she'd been talking down to me, and that she deserved that. We ended up becoming very close friends.

Lori

nurse_clown

227 Posts

when i was just starting as a graduate rn, i had a charge nurse who acted like i was a brand-new nursing student or something, constantly making sure i knew what i was doing. and i don't mean in a preceptorlike way, i mean in a way that was pretty insulting ("you do know that the insulin you're about to give is to be given sub-q, right?" "you do know you can't inject air into the iv when doing a flush, right?"). this went on for over a week, even though i had not made any mistakes and had not given any reason for such poor confidence in my nursing abilities. one night i decided to tease her- i had a patient who got tylenol elixir because of trouble swallowing pills, and i went to give it one night ("you do know that since the elixir is 250mg/cc then to give 500mg you give 2ccs, right?"). when i came back she said "everything go alright?" i said, perfectly straightfaced, "yes, he said he didn't like the taste so i gave it iv, that's ok, right?" oh the look on her face- priceless. when i laughed and assured her that i was teasing, she laughed her head off and said that she knew she'd been talking down to me, and that she deserved that. we ended up becoming very close friends.

lori

i like that one. you handled yourself well. i'm going through something similar that's getting more frustrating. reading your story has helped.

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