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.

What a horrible feeling.

:o

that feeling is unforgettable... like being stabbed through the heart with an icicle. I pray I never feel it again. But I will say, I sure as heck learned something, and that won't be forgotten either!

0 Votes

New nurse - gave a lortab to a women with a HA - on a PCA PUMP!! I had to call the anesthesiologist and tell him what I'd done and ask if I needed to fill out an incident report.. so embarassing. Ended up having to fill out the incident report but the doc was really nice about it. Most of the mistakes I've made happen when I'm stressed, rushed and overtired.

0 Votes

This likely isn't my worst but it is what comes to mind. I had a patient that would cheek his meds. He was a psych patient. The doc ordered Thorazine Concentrate Liquid. At least we could have a better chance of knowing if he was taking his meds.

Regardless of what I put the concentrate in, it was amazingly bitter and beyond horrible to get down. I finally put it in milk. As usual, my schiz patient drank it down.

I had NO idea until I saw the bottom of the cup that the milk was curdled. Thorazine concentrate CURDLES milk.

As I saw the bottom of the cup I must have apologized 10 times! I felt horrible, I made my patient drink curdled milk!

To this day he is one of my most favorite patients. He told me he didn't mind, he knew he was wrong for not taking meds to keep him from being psychotic. He KNEW the milk would curdle, I had no clue. That made me feel even worse.

It wasn't technically a med error, but yet it was. He understood I was merely trying to find a way to cover the horrific taste of Thorazine concentrate. He, the mentally ill patient, appreciated my efforts to find a more pleasing way to take his meds. I, on the other hand, felt like a dog.

One time when I was working 2-12's in a row (ICU patient, couldn't just leave him alone and everyone called in sick) I had a patient with a simple foley. I was exhausted and could no longer think. I went to inflate the balloon to keep the foley in place and it ruptured. It only took 5cc of air, not 25. I have NO clue where "25" came from, but that was what I was thinking.

The guy was a schizophrenic and they don't experience pain as the rest of us do. That was my only saving grace. The guy's bladder was plum full. Thus, the need for a foley. His reaction... bug eyed.

I flat out refuse to do 2-12s in a row. If they don't have coverage they need to tx the pt to a different hospital... one where they have fresh nurses. Understand, I am NOT blaming the hospital. I blame myself. I KNOW better than to work 2-12s in a row.

0 Votes
Specializes in LTC.
At my hospital year before last there was a nursing student that made a mistake with Heparin. Not sure exactly what happened but it was a serious mistake. The school that she was going to permanently let her go from their program. When the hospital found out about it they went to bat for the student and told the Dean of nursing there that if they didn't reinstate her that they would no longer accept student for clinicals there. They felt that it was human error and that she should not have been dismissed.

So was she reinstated? Kudos to the hospital.

0 Votes
As a student, I know that I WILL make mistakes. I applaud you for realizing and admitting your mistake. We all make mistakes..The single most important thing is that we learn from it and don't repeat it again.

Berta

Nobody's perfect! or so they say... But i honestly believe that in our profession, in which evry action we take has bearing on the safety of life of another individual - THERE SHOULD BE NO ROOM FOR ERROR:nono: ... That is why it is important to check and recheck... I really hope you learned from it, and i hope that next time, you will learn without putting the client's safety at risk..

0 Votes
Nobody's perfect! or so they say... But i honestly believe that in our profession, in which evry action we take has bearing on the safety of life of another individual - THERE SHOULD BE NO ROOM FOR ERROR:nono: ... That is why it is important to check and recheck... I really hope you learned from it, and i hope that next time, you will learn without putting the client's safety at risk..

Wow...are you an RN yet or a student? One thing you need to learn, either way, is that everyone makes mistakes. Your comment demonstrates a naivete that is dangerous.

Come back after you've been practicing for 10y and try to say you never made a mistake.

0 Votes
Wow...are you an RN yet or a student? One thing you need to learn, either way, is that everyone makes mistakes. Your comment demonstrates a naivete that is dangerous.

Come back after you've been practicing for 10y and try to say you never made a mistake.

Im not saying i wont make any mistake... But i really hope i wont... There are ppol's lives on the line here and im being paid to give them quality health care and that includes insuring that i give the most care i could give... I hope you are getting my point

0 Votes
Specializes in NICN.
Nobody's perfect! or so they say... But i honestly believe that in our profession, in which evry action we take has bearing on the safety of life of another individual - THERE SHOULD BE NO ROOM FOR ERROR:nono: ... That is why it is important to check and recheck... I really hope you learned from it, and i hope that next time, you will learn without putting the client's safety at risk..

I wonder if you are a student or are actually out there practicing. If you are a student you need to be careful because everyone makes mistakes at some point in time. You are not immune. If you never make a med error in your life, then reviewers may wonder about it because at some point in time you will be struck with the "error disease" that strikes every human at some point in time. That does not mean that we shouldn't be careful but mistakes will happen.

0 Votes
I wonder if you are a student or are actually out there practicing. If you are a student you need to be careful because everyone makes mistakes at some point in time. You are not immune. If you never make a med error in your life, then reviewers may wonder about it because at some point in time you will be struck with the "error disease" that strikes every human at some point in time. That does not mean that we shouldn't be careful but mistakes will happen.

Again, id like to emphasize the check and recheck and triple check... that way our chance of commiting a mistake will be put in mitigation...

0 Votes

FYI for the poster who couldn't think of a blue IV med: methylene blue is given IV (for methemoglobinemia).

0 Votes
Again, id like to emphasize the check and recheck and triple check... that way our chance of commiting a mistake will be put in mitigation...

And I will emphasize again that we are all human, and at some point, even the most consciencious nurse will make a mistake. It's really inappropriate to sit in judgement of someone when you have not actually been in the position of practicing as a licensed nurse.

The textbook/ideal world you hear about in school and the one you actually practice in are two different settings.

0 Votes

I remember a nursing instructor I had who once said that any nurse who has been practicing for several years and says she's never made a med error is lying.

0 Votes
+ Add a Comment