Your Worst Mistake - page 31

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,... Read More

  1. by   RNOTODAY
    Quote from Brenda-RN,BSN, WA.
    Not only are nurses human, so are doctors. I have a personal experience regarding a doctor that made me realize that they too are only human, and they have even bigger consequences to face. My oldest son who is now 5 was diagnosed with a life threatening heart condition by accident. I took him into the ped. because he had a bad cold. Our ped. was out on a leave so we saw a different doc. He did a full assessment on my son since he had never seen him before, thank goodness. Anyway, he heard a murmur, which had never been heard before, and got a horrible look on his face, and said that we need to go to a ped. cardiologist within the next week. We had an appointment set up, but I had to take him back to the ped. a couple of days later because his URI was getting worse, by now his regular ped. was back. She listened to his heart and said it was a normal murmur, and to not even go to the cardiologist. Well, I did because of the look on the other doc's face. Two months later we were at Stanford Medical Center having open heart surgery. We live in Seattle, and were told they couldn't perform the surgery because they had only seen my son's condition in autopsies. Our regular pediatrician made a mistake, we still go to her becasue we really like her,and she is human. Many people we know think we're crazy but I have to say, when we go in, or call, we get fast treatment, and all of my kids get a more than thorough check each time. I think everyone needs to realize that we all make mistakes, but as long as we learn from them that's what counts. If there's anyone reading this from Lucille Packard Children's Hospital, or Stanford, thank you, even if you did not have anything to do with my son's care, they are both wonderful hospital's. And Dr. Hanley is a miracle worker!
    Seriously? That doc totally and completely missed a heart condition, ignoring the murmur.. your child needed open heart surgery-- yet you STILL trust this doc with your children's healthcare??? WOW you are far far more forgiving than I.. I would have , among other emotional things, sued his ass off...
  2. by   al3x117
    Quote from reyna
    my biggest mistake was...going to nursing school just kidding
    HAHAHA!!!! OMG! Thank for the laugh!!!
  3. by   canoehead
    Quote from NurseNili
    here's a few of the mistakes i have made in my illustrious nursing career: not getting enough sleep between shifts and being dead tired at work, which distorts judgment and critical thinking skills; mistaking "unit" for "cc" (read: gave wayyyyyy too much insulin iv", accidently infused an entire litre of ns into an 18 month old child, while trying to clear air from an iv pump and running it wide open to feed the saline through (new infusion pumps have helped eliminate that mistake), mistaking a bbb for v-tach, and precordial thumping someone who was awake and alert (can we say duh????), instilling "antibiotic" eye drops into an 8 year old child's eyes, only to discover that i grabbed the wrong bottle and instilled pupil dilating solution into her eyes (always remember that a red capped bottle of eye drops indicates "dilator", a helpful hint from my opthamologist), giving 10 mg of calcium chloride ivp over 30 seconds for a patient with a high k+, all the while watching the patient's rhythm go from nsr to sb to asystole, and not recognizing that this was happening, before a co-worker ran into the room and administered atropine (the patient lived, but i just about died, and now i give calcium chloride ivpb over 10 minutes), do i need to go on?

    point is...you can make mistakes and still be a fabulous nurse, as long as you learn from them and never do them again. i am very fortunate to be working in a facility that has a non-punitive med error policy...they always say "it's a system error". gotta love that, but actually, it usually is, it is almost always not just one person's fault, there are usually contributing factors for pretty much every situation. my excuse? as an er nurse in an ed that sees over 200 patients per day, many with high acuities, i am always in a hurry, but taking 10 seconds to check myself for critical errors has prevented me from making more mistakes...don't let any nurse tell you that they have never made mistakes. every one of us has, to error is human, right?
    THESE MISTAKES ARE NOT THOSE OF A FABULOUS NURSE.
    I'm pretty forgiving, and I've made some doozies, but for maybe the second time in my allnurses life I'm saying that if one nurse made all these mistakes, s/he needs to stop before someone dies.
  4. by   setsuna92
    My worst mistake... piggy backing magnesium and delivering an excess of 100mg to a patient. I was told by the pharmacy to just hang the bag and set a timer, which I did. But I should've known that the timer wouldn't stop the infusion since it was piggybacked to a bag of saline that was set to run by the hour. The whole bag of magnesium was given to the patient. She did not suffer from any physical side effects, but her Mg labs were critical high by a couple of points. Got MAJORLY chewed out by the on call doc. But her actual doc told me to just "not do it again." He was super chill about it, and the patient was released two days later. I was investigated, but ultimately they found pharmacy to have violated a policy on providing exact doses of electrolytes for infusion. It actually traumatized me, but about two years later, I'm finally finding peace.
  5. by   VivaLasViejas
    I didn't make very many med errors during my career, but my worst one was the time I gave a Lovenox injection to a patient and then gave him a heparin shot on top of it. He and another man with the same first name and similar last name ("Harry Smith" and "Harry Smythe") were in rooms next to each other, and I simply did not do the five rights. Stupid thing is, I was questioning in my mind why the poor guy needed heparin AND Lovenox, but I misread the name on the MAR and ass-u-med he was getting both. Long story short, I discovered the mistake when I went to give the other patient his meds and saw the heparin order, then quietly freaked out before I notified the doctor of what I'd done. I couldn't believe it. I felt like the worst nurse in the history of the profession. This error came at the tail end of my career, and it made me realize that the difficulties with attention and focus I'd developed over the previous couple of years made me unsafe, and I needed to quit before I killed somebody. Luckily no harm came to the patient, but I still shiver whenever I think of the incident.

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