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 Pediatrics.

Last night was a big mistake for me... I feel terrible. I had a very active little baby, sitting up and able to crawl and stand, whose mom was already kinda anxious and upset about some other things that had happened. She asked me to change his IV armboard cause he'd been eating and got some food on it, and so I got the side rail of his crib down and stood in front of him tearing tape. He reaches for my tape roll, tips forward, and before I can catch him he has fallen head first straight into the bedside chair. I thank God that chair was there and he did not hit the tile floor- I shudder to think what the outcome could have been and all my fault for not catching him. It was the most awful feeling!!! The baby had fallen once before during his admission, and now will have two knots on his little head. This was early in the shift and you can bet the rest of the night I kept a very tight hold on this kiddo whenever I needed the rails down to do ANYTHING!!!

When I was brand new passing meds about a year ago I had to pass my meds at a furious pace. I had two full carts to pass simultaneously yet I had to be time compliant and still expected to run after alarms and answer call bells. It was a very dangerous setting. Thank God they have lightened my load since then...:)

I'll tell you my worst mistake was about 18 years ago. I was working the evening shift on a chemo ward. A fairly new doctor had prescribed the chemo (100mgs cosplatin) and the pharmacy had mixed it up. I knew the dose was incorrect according to the protocol so contacted the patients consultant, who came & changed it to 200mgs. Since it was after 6pm, & pharmacy had closed, I had to add the extra 100mg myself (nurses could do that in those days) which I did around about 8pm. The ward was furiously busy & as I finished the mixing, one of the nurses put out a cardiac arrest call. I naturally went to the call, finished my shift at 9pm & went home, completely forgetting that I had not changed the label to indicate that the additional cisplatin had already been added.

Enter the night shift... they noticed that the script said 200mg but the label indicated 100mg & added a further 100mg, making a total of 300mg

For those of you who have worked with this drug, the consequences are renal toxicity, severe nausea & vomiting and ototoxicity, to name a few. That poor man had puked all night long, and the staff had given him everything to relieve his N&V (Kytril & Zofran had not been discovered at this point) His renal function according to his lab work was a mess and he had constant ringing in his ears and ended up with permanent partial hearing loss.

I owned up the very next morning, as soon as I realised my error. My manager was brilliant, the consultant was brilliant and the patient was brilliant. I feel sick every time I think of that error

I praise you that u admitted your mistake...This types of mistakes should be shared so others remain alert in their practices at clinical area.

After reading all of these posts I am thankful that my biggest mistake to date is more embarrasing than life threatening. It was my first week as a GN at a teaching hospital. My preceptor was very comfortable with my skills and decided that I was more than capable to deliver meds without her. She would be in the nurses' station (playing games on the computer) if I needed anything. Well, with a swelled head from the compliment, I proceeded to give my 6 pts. their medications. I get to Mr. X and start collecting his meds and notice that he is to receive " two sprays PR" of this Hurricane Spray. I'm thinking to myself, why would be "spraying" his rectum? I go ask the RN (who is having a ball in the nurses' station) and show her the order. She confirms the order and , stupid me, doesn't ask why?

I go into Mr. X's room and explain that I have to spray his bottom. He gets up, doesn't ask why? and leans over the bed. I spread his "cheeks" and give him 2 large sprays. Well, he starts dancing around and waving at his behind and tells me that it's burning and can we wipe some of it off. I say sure and give him some tissue. He finally settles down and I go off to the next pt.

About an hour or so later, I still can't understand why we would give this guy butt spray. I take the can and go to the pharmacy. They tell me that it's Hurricane Spray and it's for the throat. (Duh??!! My guy has an NG tube). The order should have been PRN and the unit clerk misread the order. I am mortified. I go to the RN and explain the situation. She laughs and says to give it PO. I can not tell this poor guy that I just sprayed his *** with spray that was intended for his throat. So, I play it off, " Guess what Mr. X, the doctor has ordered another spray and this one's for your sore throat!"

I could barely tell my husband what happened that night, I was laughing so hard. This guy probably warned his friends not to go to that hospital, "they spray your ***!! Bet he wondered why it wasn't on his bill. Compliments of the nursing staff.

This taught me to trust no one when it came to delivering meds.

At the hospital I used to work in, we had an RN who made a pretty drastic med error... on herself. Here's the story:

She had laser eye surgery to correct her vision, and decided to go to the beach that weekend with her family. At the hotel, she went to get her eyedrops out of her overnight bag...and grabbed a bottle of superglue instead. Yup, drop of superglue straight in her eye. In pain and scared, she had her hubby call paramedics (her eye at this time was glued completely shut.) Apparently she knew that nail polish remover (acetone) removes super glue... so yup, rubbed nail polish remover into her eye while waiting for paramedics. Long story short, she had to have the surgery all over again and she probably won't ever live it down. (Thank God though, she didn't lose the sight in that eye).

Some mistakes are not med errors. A few years back this one CNA co-worker told me about that sick feeling she had when she realized on her way home that she had left someone on the toilet. She hurriedly returned to the facility to find the resident still sitting on the toilet. She said she just felt sick and was glad the resident was ok ( except for a nice ring on her bottom).

I think this thread is incredibly valuable- it has given me a brainload of things to watch for, and consequences that can happen if I don't. Thank you everyone for sharing! Keep them coming!

Lori

Specializes in PeriOp, ICU, PICU, NICU.

Not finished reading the entire thread but very interesting. Thank you all for sharing. :)

Ok...this is NOT a worst mistake, but it was a wake up call for me. Yesterday an A&O resident went to hospital on day shift. came back about 4pm. did my assessment on him (he's COPD non compliant with tx), so my assessment was focussed on resp/cardio. did my 9pm medpass and about 10pm he calls me to ask if I can take his foley out. am like "am sorry, do what??"" he had come back with a foley and I completly missed it. I mean I missed the big ol' bag hanging from the bed, the long tubing going down the side etc... and it wasn't even a busy day for me. It just made me stop and reassess everyone. man it made me feel aweful

Specializes in Transplant, homecare, hospice.
As a student-to-be, my worst fear is making a medication error. I haven't even started school and I've been reading chapters in nursing books about drug calculations, and I practice these calculations when I can. I can see myself as a nurse triple, quadruple checking to see if I've got the right medication, delivery route, right dose, and most of all, right patient!

Hi there. Unfortunately, to err is human. When you feel overwhelmed, stop, take a deep breath and get your thoughts reorganized. I do this now. I take about 5 to 10 minutes to figure out what is needed...I get my thoughts organized. I make sure I know what needs to be done. I would rather stop and do this than jumping in head first and making a mistake that could harm my patient. If I can't stop for whatever reason, I summon help.

It's gonna happen. Mistakes. And when it does, don't beat yourself up over it. I know I did. I need to eat my own words. But it's true. Everyone makes mistakes. Good luck with your schooling.

Oh and one other thing...when you DO make a mistake, I can say most likely, you will never make that same mistake ever again. It makes an impression on you that you'll never forget. :wink2:

Specializes in Transplant, homecare, hospice.

I'll have to say that the worst mistake that I've made is I ran Amphotericin in with a pre and post flush of D5NS. Ampho is to be flushed with only D5W...ONLY! Or so I'm told. When Ampho and NS mix, it crystalizes in the line. Needless to say, I called everyone under the sun that night to make sure my patient wasn't injured from my mistake and he wasn't. It was a $2000 mistake and I occluded one of the lumens on his picc line...that scared me to death! What a horrible feeling.

:o

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