Your Worst Mistake

beachmom · Oct 8, 2006

I was a new pediatric nurse floating to the oncology dept. While only certified oncology nurses can give chemo, any nurse can give the rescue drugs given immediately afterwards to protect the organs from the chemo.

On the MAR, the regular drugs are all together and the prn drugs are on the next page. Well, my pt. had just finished chemo, and leukovorin (sp?) the rescue drug, was on the next page, kind of by the prns. I didn't understand why it was on a separate page, so I planned to ask. (Chemo and rescue drugs get their own page.) I got busy and didn't ask, and by the time I noticed, the leukovorin was 3 hours late! To make it worse, her SL would only flush if the IV was held in a certain position. I didn't want to waste time starting a new IV, so I held it in place until it was finished.

Then I went in the bathroom and cried. I felt so awful!!! The chemo nurses were very nice about it and said the pt. probably wasn't harmed, even though from their expressions, I could tell they weren't sure. It made it worse because the pt. had been harmed in the past by a nurse's med error. I filled out a med error form, but never heard any more about it.

A month later when I floated to that unit, they were discussing another non-oncology nurse who made a similar error as mine. Not long after that, they changed the rules to where only oncology nurses could do rescue drugs. Thank God!

beachmom · Oct 8, 2006

Judging from the number of posts of med errors involving insulin, I can see why many places have the policy of two nurses checking insulin. We do at our hospital.

I've noticed if I just tell the pt. "Here's your meds" they will take them without question, but I have been saved more than once by saying, "Here's your ....... for your ......." and the pt. will catch problems.

One diabetic's doctor had increased her insulin while in the hospital, which is common as their BS's often increase. She said it was way too much, so I asked her how much she wanted. She said she would take half the dosage. I just charted what I gave her, and that the pt. refused the full dose. Her blood sugars were fine the next morning. This happened two days in a row, so I left a note for the doctor about it. If I would have obeyed orders, she would have bottomed out during the night.

My fellow nurse just a couple weeks ago was giving metoprolol. Due to a transcription error, the MAR said 150 mg. This is triple the normal dose, but the nurse was really busy and didn't think about. The pt. even said she shouldn't have that much, but the nurse gave it anyway. The pt. ended up in ICU. The nurse can't believe she actually was so rushed so as not to notice that blatant of an error. She's a very good nurse, usually extra careful.

TazziRN, RN · Oct 8, 2006

This is how scary insulin is: my facility used to have just one RN on in the ER per shift (at that time we only had 3 beds). We did not have witnesses for heparin but we ALWAYS called a nurse from the floor or the house supe to witness insulin, or we got the doc to witness it. Now we have two RNs on at a time, so that makes it easier. (Makes life in general easier......wasting narcs was a tad difficult in the old days!)

emmalou* · Oct 8, 2006

I have always felt that Insulin is the 'scariest' drug - I don't mind giving morphine or pethadine, or IV antibiotic pushes; have done heaps of those without worrying in the slightest, but Insulin, to me, is one of the most dangerous drugs.

I was team leader in a medical/rehab ward where the RN gave out the meds and the other nurse you worked with, usually an enrolled nurse (or LPN in US/Canada) would help out with the other cares. I was tired and had done a few late/earlies in a row (no excuse!! But, in Australia, we can finish work at 11pm and start work at 7am the next day and it does mess you about a bit). Anyway, one of my ladies was having her PEG tube removed that morning and was on the early theatre list and was a diabetic. Well, you can guess what happened - I gave her the regular insulin dose, forgetting she was nil by mouth. I actually didn't realise I'd made the mistake until a couple of hours later when one of the other nurses, a friend of mine, walked up to hand her over to me after coming back from theatre and said "some idiot gave her insulin before she went into theatre, and they had to put up glucose".

You can imagine how I felt. I admitted it right away and the lady was absolutely fine.

I lost sleep over that for WEEKS. Ever since then I have checked and checked and rechecked insulin orders and haven't made an error with insulin since.

I don't need to tell you guys, there is nothing like that ice cold feeling you get that washes over you when you realise you've made an error. Its nothing I could explain to a lay person. :(

purplynn · Oct 8, 2006

:madface:OMG! brand new nurse and alone on the floor alone. Roxanol came in a box label 10:1 instead of 20:1. Not being familiar with normal concentrations I gave too much. Someone had crossed out and corrected on the narc log but not the bottle or box. Talk about wanting to throw up!! All turned out well. I was lucky enough to be working with very supportive nurses! :nurse:

We were taught to double check insulins...but who do you check with when you are the only nurse in the building?
Has anyone had a serious error from the Pharmacy and not noticed?

purplynn · Oct 8, 2006

what is nph insulin?

:nurse: NPH insulin:

an intermediate-acting insulin; NPH stands for neutral protamine Hagedorn. On average, NPHinsulin starts to lower blood glucose within 1 to 2 hours after injection. It has its strongest effect 6 to 10 hours after injection but keeps working about 10 hours after injection. Also called N insulin.

solumedrol · Oct 8, 2006

NPH insulin:
an intermediate-acting insulin; NPH stands for neutral protamine Hagedorn. On average, NPHinsulin starts to lower blood glucose within 1 to 2 hours after injection. It has its strongest effect 6 to 10 hours after injection but keeps working about 10 hours after injection. Also called N insulin.

Interesting.. Thanks for the information. I'm a nursing student and there is just so much stuff I still need to learn.

NewEDRN · Oct 26, 2006

I made a stupid mistake the other day. I've been a nurse for a little over 2 years, recently moved from the icu to er. We had a pt the other night who was a terrible stick- 3 nurses, 2 lab personnel, and iv therapy were unable to draw her labs. Finally, the doc and i go in to do central sticks, atleast 7 or 8 jugular, and more than 10 groin sticks before we finally got some labs. Her coag tube was the tiniest bit short, and before we could draw another one, coud'nt get anymore blood. The pt had been there 10 hrs and was on coumadin, the only thing she needed was labs resulted and she could go. I dont' know what i was thinking, i had a bunch of tubes that were half full, and half kidding to another nurse, i said i wish i could just add a little to the short tube, she states, i've done that a million times and never had any problems. So, i proceed to pull some blood with a syringe out of a tube i thought had no preservatives or anything in it, add it to the coag tube, and send them out, without even considering the conseuquences at this point, the doc says to me, i really hope those coags get resulted, cause i'm not sticking her again, and i say to him, they should, i filled the tube the rest of the way with a discard. Needless to say, labs come back all messed up, and when called into the dr, (who knows very little about how the lab works), states, could it be because the nurse put a little extra in the short tube?? at this point, it becomes crystal clear what i have done, the tube i added from did have a thinner in it, and hindsight what it is, it's now so very clear why you're not supposed to mix tubes. I don't know what the heck i was thinking when i did that, i've never done it before, and certaintly won't again. I told my supervisor, who laughed about ti and told me not to worry about it, but i know the incident reports go to the department heads, who are not so nice and understanding. I'm feeling so sick right now and hope i'm not going to lose my job over this. luckily we just cancelled the labs, and the pt went home with instructions to follow up with her family doc. As much as i cringe over my series of mistakes, i am glad i admitted to it, if it had'nt been detected, the pt could have wound up admitted getting FFP and several more lab sticks.

rita359 · Oct 26, 2006

One time I miscalculated a dose of Roxinol and gave the patient 4x the dose that she was supposed to get. I had to give her Narcan. I was ready to turn in my lisence. I felt terrible. Now I have someone double check any calculation dose for a med that I haven't given before. Probably drives my coworkers crazy but I will never forget the sick feeling in the pit of my stomach.

And a pharmacist I know misprinted the instructions for a roxinol dose on a patient being cared for at home. The family gave the massive dose of roxinol according to the directions and the patient went into respiratory failure and died. They had no clue the dose was inappropiate and no way to check. Fortunately, we have ways to check appropriate doses and narcan or other appropriate antedotes easily available.

DutchgirlRN, ASN, RN · Oct 26, 2006

This thread is both informative and terrifying as an RN and a potential patient. As a preceptor I have prevented several serious mistakes from happening. All involving insulin.

The one piece of advice that I would have for new nurses is that just because a doctor orders something doesn't mean it has to be given. ALWAYS question any order you think is not appropriate no matter who the doctor is. They, like us, can and do make mistakes.

I had an order once for 100mg Morphine/Phenergan 25 mg IM Q 4 PRN Pain. The student I was precepting didn't question it because it was a doctors order and must be given as ordered. I called the doctor...

"Um dear doctor _________, I'm assuming you meant 100mg of Demerol IM Q 4 and not Morphine? Would you like me to correct that order?". God yes and THANK YOU so much for saving my a**.

Also, when a patient comes up from surgery with a PCA ALWAYS double check, with another nurse present, to check that the pump was programed correctly in the PACU. It has happened twice that I know of in my hospital with near fatal results.

danissa, LPN, LVN · Nov 7, 2006

:imbar !! I felt that My worst mistake to date, was not with a patient but with my dd Hollie! I was 18 yrs old when she was born and not a midwife at that time.Around 4mths old she had an ear infection, doc gave me Amoxil--WITH Syrynges!! Remember guys, 18, NO previous baby experience-- What to do?? (NEVER HAD SEEN SYRYNGES PO!) So, I gave the meds in her EAR, only when my Mum noticed the bright yellow sticky goo, (after a good few admins!) and screamed out, she thought the infection was ooozing!! BUT it was the amoxil running out ! OMG!! So mortified!! By the way this fab girlie is now 19 yrs herself and has PERFECT hearing!!! I know its not as scary as some of the other guys experiences, but I felt like the worst mammy in the world at that time. I ALWAYS stress to parents the right route etc, for drug admin, & never take for granted that they will know:trout: !

crackerjack · Nov 13, 2006

I've spent the last few days reading through this entire thread. I'm a new RN *grad in May* and am finding the entire thing informative, relieving and petrifying all at the same time. So far I'm fortunate not to have made any truly crucial errors. Orienting as an OR nurse, most of our meds are given by anesthesia docs. There are many things we do that can result in harm to the patient but having 1 patient at a time plus a preceptor by my side (most of the time) there is a lot less likelihood of error. However, it can and does happen.

Errors outside of med admin are the ones that trip us up. I made the mistake of accepting demonstration of the proper way to open and pass off alloderm tissue onto the back table rather than reading the directions. I had been taught to open the outer package and allowe the scrub to extract the inner package. So, that's what I did the next time I had a case that needed it. So did my preceptor. Then I happened to read on the front of the package - yes, right there on the FRONT, didn't have to open an instruction booklet even - it states that the inner package is NOT sterile and that it has to be opened by nonsterile personnel to be passed. I see this and point it out to my scrub, preceptor was out of the room at the time, and her eyes turned into dinner plates. I left and got my preceptor to tell her what we were doing wrong but mostly so we could tell the surgeon together as he is one of our more pita docs. Preceptor was horrified as she's always opened it that way. Our dept educator was in the hall and we talked with her about it and she was bug-eyed as well...and thankful she wasn't the one to have to tell this doc the news that the grafts he was stitching into the patient were contaminated. We cringed and cringed and cringed, finally worked up the courage to step back into the room. Then we cringed some more before my preceptor finally speaking up to the doc to tell him that we had opened the pkgs incorrectly and the product was contaminated. To our surprise, he didn't scream like he usually does. He made some comment about it couldn't be helped now and we'd just make sure to give extra antibiotic. Since my preceptor told the doc, I said I'd call and talk to our director to tell her what happened so she'd know what was going on before she got her copy of the incident report via email. She was awesome, never said a negative word. Thanked me for letting her know and for taking care of things. I never heard another word about it from anyone. I never told anyone that the person who taught me how to open it was the same scrub who was in this case. Our educator and my preceptor asked and I told them I couldn't remember it had been so long but since my preceptor was also opening them incorrectly nobody pushed it seeing as how it was clearly a problem before my time. Needless to say, by the time the case was over everyone in our tiny OR unit had heard about it. Nobody was nasty about it though so I was thankful. As far as I know the patient was fine so lesson learned. I think there was a unit wide email with info on how to properly open those packages and maintain the sterility of the contents onto the sterile field.

Later the same day after that incident, we were positioning an anesthetised patient into prone position. Once prone, the LPN on the side opposite me was rotating the person's arm to position onto the arm board and the end of the picc line was ripped off. I don't know if it was done when she moved the arm, when the chest rolls were placed or when we flipped the patient prone. Since I was on the opposite side I couldn't see but given the circumstances and what was going on, I have a feeling it was when the arm was rotated. It was still my patient, my room, my responsibility and I should've been watching out more closely. Being the orientee working the room without a preceptor, I was trusting that the LPN helping to position was being cautious about such things on her side of the patient. Once again, I had to tell a surgeon something about his patient that shouldn't have happened. This guy is usually nice but has his temper tantrums. I got the patient situated, cleaned up, gave report to the relief nurse and went to find my surgeon. I told him what had happened and he was very cool about it. Someone had already told him and he said it was no big deal (I beg to differ) and they'd just put it back. All well and good, thankfully the patient was already having surgery and it wouldn't incur quite the cost as a seperate procedure but still....

Those are my two biggest mistakes thus far. I would love to live in denial and say I'll not make another but pppppfffffftttt we all know that ain't gonna be the case!!! I can't thank everyone enough for sharing their humanness. It scares me to death to know that *someday* will come and I fear what will happen to my patient for my mistake. I dread it.

On a positive note...recently I had a preference card that called for the mixing of two drugs into NS onto the back table. One of our scrubs saw me looking up the meds and asked what I was doing. I told her and she looked at me as if I were insane to even think of checking them. She told me that while it was good that I was being cautious and all, with *that* doc I could/should just accept his orders because *he knows his stuff*...some other docs it would be good to check though. I told her that while he probably does know his stuff, I don't know it all and I wanted to be in the habit of checking rather than assuming and if I skip checking this one it'll be easier to skip another one and regardless of who ordered it, I have to be responsible for knowing the drugs I'm administering and if I miss checking one and a patient is harmed, it's my license. She accepted it as a good thing...that I was using it as a learning tool, not that I was being responsible for the meds I'm administering. Oh well. LOL It clearly isn't her license.

Thanks again, EVERYONE!