Your Worst Mistake

[aurora_borealis]

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.

[LoriAlabamaRN]

How high was the resident's blood sugar to start with? I assume she had to take it before she administered 80 units of insulin.

Her blood sugar was a little under 200, I think in the 190s. She's a relatively new nurse, and has been very shaken up by this. I'd bet my boots she will be the safest insulin administrator in the place from now on!

[kelliebell2002]

was in the same situation.....my patient choked and was a DNR. I partially removed the obstruction but when the emts got there they re-lodged it and the man died. I had to go to court to do a deposition and was informed by the prosecuting attorney that it does not matter if someone is a dnr or not in an emergency situation.....you always do cpr in that situation reguardless of the the dnr status

[kelliebell2002]

that made me laugh....when i was first out of nursing school ages ago , I went in a pts room to give a supp. she was large and obese and I had her lay on her side to insert it and didnt pay close attention to what i was doing and inserted it into the lady parts. I freaked out and tried to dig it out and the whole time she was making pleasure moaning sounds. I was completely horrified . I will never forget it. after a minute I just left it there and walked out of the room to recover....

[jerseyRN]

truly a comfort measure. that story cracked me up!

[kelliebell2002]

I worked on an oncology unit and we had two pts in which we were waiting on the labs to see their blood counts before they could go home. the lab came and drew their blood but got the tubes switched and we sent the one home that had bottomed out lab values and kept the one that had normal values and gave her a blood transfusion. we had to locate the other lady and she was at her grand daughters graduation, but was able to get back to the hospital. needless to say the lab tech was fired.

[Lara911]

I was a student nurse in a trauma department and I had a patient with Y jejunostomy, with 3 ends, one for the food, one for meds and one for the ballonet. I put my syringe with meds in the good one and a nurse of the floor came to see and told me I was not on the good one, I looked at her with doubt but did not say nothing because she was the graduated one so I told myself I must be wrong...she came by my side and told me, put it the blue (or green or whatever was the color,) so I did and start to push but it was resistant, so I stopped and told her, I can't push it in here, she was impatient, took the syringe and gave the first 10cc and told me, it goes there, what is your problem, si I wanted to give the last 15 cc, then..BANG I heard a terrible sound and so is the patient..I ran see me teacher and she told me, you broke the ballonet!! I felt so bad, the patient had to go under surgery again...but me teacher kept me in the team because usually I was a good stugent, and she asked that nurse the fill out the accident report...and told me something I will never forget...HAVE CONFIDENCE in yourself when you know you are right and be careful who you trust...

[JentheRN05, RN]

My worst all time mistake was my very first diabetic patient after starting on the job with a preceptor. Not having worked with many diabetics during nursing school I did not recall the fact there was a diabetic med sheet seperate from the regular med sheets. When getting meds ready following the med sheet to a

'T' and checking and rechecking my meds I drew up the ordered insulin, took it to my preceptor to check (required for all insulin in our hospital) and she cleared it and I gave it. Later that day the patient was to be transferred to a different floor. When writing up the transfer order and going through med sheets I discovered my own error! I had given the entire days dose of insulin at one time! It was horrible the sick feeling I felt, but I immediately went to my preceptor and told her, then went to charge nurse told her, then had the job of calling the doctor (who was calm on the phone but said she'd be right over) and lastly informing the patient (of course I had checked on the patient immediately but didn't disclose the news until I went through the proper channels). The patient was required to stay another day before transfer (which stunk because this patient had been anxiously awaiting this transfer for 4 days!!!). I monitored the patient very carefully and feed him ice cream and made sure he finished his meals my entire shift. A half hour after the phone call to the doc, she showed up on the floor demanding to see me. Took me in a room and proceeded to chew me out. My preceptor came in in a couple of minutes (after I was already in tears) and said, she cleared this with me, and I missed it to, the blame is not entirely hers because I should've noticed the dose - she even told me!

Anyway - the blood sugar checks were not increased, only told to watch for s/s of low blood sugar. So watched patient carefully all day. 4pm bs was within normal limits! Of course I knew it would be because I believe it was Lantus that I gave and the drop wouldn't be until 16 - 20 hours later. I informed the oncoming nurse of my mistake and before I left I made sure the patient had eaten all of his dinner, and suggested the night nurse give him a snack high in sugar :) His 10pm bs was slightly low, but not out of safe limits, and his 6am was also slightly low but not out of normal limits. BOY was I ever lucky. I tell you what. I NEVER made another insulin mistake after that!

[RebeccaJeanRN]

This is actually a really interesting thread...that we'd have enough courage to admit mistakes, and to show brand new nurses (which I too am, despite the fact that I'm so much older than the traditional new nurse!) that you can make a mistake and live to tell. One of the greatest stresses of nursing is the concept that you can't make a single mistake, which unfortunately is nearly true. Thanks for these posts! Now for one of MY mistakes, I gave a patient a shot of Lovenox with the cap on the syringe. Yep. Hard to believe, but it was a new styled prefilled safety syringe that I never saw before and I swear the grey cap looked just the rubber safety tip on the holder end of a vacutainer needle. I couldn't make out the cap and thought I must have removed it already and misplaced it. Only when I pressed it against the patients belly and proceeded to 'inject' her, and saw the fluid running down into her body's dark recesses, and all the while saw her smiling because it was so painless, did I realize my mistake. How embarrassing as I had to get another syringe ordered and knew that the patient was witness to my ineptness...

[lovemyjob]

I really needed to read this whole thread. I have been a nurse for 2 years and only since I have gone into NICU (1 yr)have I made my med errors...yes, that was plural..and I have been feeling terirble lately.

First one: I crushed a PO pressor (chronic kid) and then instead of giving the kid his ordered dose, I was so focused on the process of what I was doing (had never done it before, still in orientation) that I didnt realize I gave him the whole thing...through an ND tube...yeah the one that gos straight to the intestines...like a vaccum. I think it ended up being about 100 times the dose. I ran to my preceptor in a panic and we tried to pull ikt out and got a little back from the tube. Called the doc...the whole nine yards..luckily he didn have any probs from it. I spent the night questioning my career choice and with knots in my stomach. watching his q 15 bp's.

THEN, the other day, I accidentaly gave a kid his q12 NG phenobarb 5 hours early....made me feel sick. I was able to suck it back out before calling the doc, who didnt call for any changes...still give at regularly scheduled time. The prob is, the reason I screwed up was because I wasnt paying attenetion..it was an easy night where I had good pts and I was chatting ewith coworkers. I was plain old carelss and didnt do the triple check I usually do..check MAR beofre going to the pyxis, check the med with the MAR at the bedside, and check it again when I put the needle in the line or hook it up to the pump or put it on the end of the tubing...I always do tht third check, and I didnt check anything except for them med amount..didnt even look at the time, thought I rmembered it from report. I just feel like an acciident waiting to happen. I feel like a walking time bomb. Really makes me think I should get out of the field, but then I wonder what else I would do... ugh, it is such a horrible feeling. O know I will get over it, bt it still makes me sick to think if it.

[Elisheva]

Well, maybe this isn't the thread to read at 1:00 a.m. on a day when you've had a lipoma excised from your head (in the surgeon's office, no less.....a decision I won't repeat). I'm planning to return to nursing after several years of being awol, and, frankly, I don't know if I can do it. I had one minor med error several years ago that almost just put me over the edge. I just could not get over the shake in my confidence.

I appreciate the willingness of all those sharing here. In a way, it's very healing...it's not just me! In another way, it's entirely frightening because we are all so very human and mistakes are just a part of life.

I need to develop some good coping skills, some major confidence, and a healthy dose of self-forgiveness if I'm going to be able to do this job. Really ticks me off....I know that, despite my obsessive fears, I am a really good nurse.

[TennNurse]

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.

:rotfl: :rotfl: :rotfl: :rotfl: :rotfl: :roll :roll

This is the funniest da*n thing I have ever heard!!! 20 minutes after reading this I am still laughing at it! My eyes are watering and I am starting to wheeze......

[sanctuary, BSN, MSN, RN]

:rotfl: :rotfl: :rotfl: :rotfl: :rotfl: :roll :roll

This is the funniest da*n thing I have ever heard!!! 20 minutes after reading this I am still laughing at it! My eyes are watering and I am starting to wheeze......

:yeahthat: :yeahthat: :yeahthat: :roll :roll :roll