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.

i was working ltc and we had just got this elderly couple. the man was very very aggitated. he drew back like he was going to hit me. i place a call to his doctor (without pulling the chart) and his usual dr. was out of town so i got the dr. on call. i told him what was going on with the elder and he tells me to give him 1mg of ativan po now. i call the rn supervisor and get the ativan, take it back to him, he takes it, and i go to write the order. when i pull the chart, in big red letters is allergy: ativan :uhoh3: i called the dr. back and ask him for something else...he gives me an order for a non-narc. med. i go to the nurse i am working with, i feel hot and sweaty and on the verge of vomiting, i become hysterical and she tells me "sweety, we'll fix this...come with me" so we look up how it effected the elder (gave him heartburn) and she tells me that we will keep it quiet just to watch him. he did become very very sleepy...but he did sleep through the night and felt better the next day. i learned very very quickly to ctcfa...(check the chart for allergies)

i still feel guilty about that.

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Boy, admitting is hard, but we know we have to do that, forgiving ourselves is almost impossible.

I was fresh out of LPN school, working evening shift by myself, pt chokes in dining room, I called out for a code status, the SSD went and checked the chart, running back in and yelling, "She's a Full Code" so I began CPR, the pt was revived, the EMT's arrived, and about 30 minutes later the hospital calls, and notifies us that the pt was a DNR on their records. I went to check her chart, and although there was no yellow flag in front of chart, or a sticker, or even an order on the current MAR, looking back about a year, there it was, the Doctor had wrote an order for her to be DNR d/t terminal illness, it was never pulled forward. She was in the hospital for about a wk, and I was so worried about the state that she would be in when she came back, but she came back as the same old fiesty lady, which made me feel better. But just imagine, the adrenaline of the code, excited about actually doing a code successfully, people patting me on the back, feeling 10 ft tall, and then the call saying that she was a DNR.

So....my big ole soap box wherever I work is asking what the status is, asking what the family wants if they've changed their mind with decline in conditions, and making the SSD aware, nurses, CNA's, whoever what a pt's code status is.....it was a horrifying experience....

On the lighter side, I have inserted a foley in the wrong "umm" area, and reported no output at end of shift, to have dayshift find out, I wasn't a very good mark.

And we all know how scary it is when you realize that you have given the wrong meds to the wrong pt, fearing the worse, not wanting to call the doctor, and kicking yourself the whole time knowing that is was just plain dumb, or rushing or whatever.......

To the RN that quit because of the Insulin? You really need to get over this, 50 Units was a tad bit too high, but we all make mistakes, don't give up something you love......that is so sad......you are probably a very competant nurse, obviously caring if it has affected you this much, go back to doing what you love.....

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Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
My error has kept me from working since the day it happened. I so terrified that I may make another mistake which may lead to a patients crash or even death. It was a busy day and I was overwhelmed (still no excuse) and my patient was on a sliding scale insulin. I took the blood sugar and she required FIVE (5) UNITS of insulin. to this day I do not know what was going through my mind but I pulled back to FIFTY (50) UNITS instead of the minimal FIVE (5) she needed. I did my checks that it was the proper insulin. I took the patients medication profile to her bedside and compared her armband to the profile and I stated to her that I was there to administer her insulin.

Still not knowing that I had done the error I left the hospital at the end of my shift which was about 45 minutes later. I had helped her with her tray and asked her if there was anything I could do for her before I went off shift. (because sometime report & shift change take a while), she replied no.

I was at dinner with my husband at a resturant and while eating my soup, which was the first part of my meal, IT HIT ME WHAT I HAD DONE! My husband saw my face and asked me what was wrong I immediately grabbed the cell phone and tole my husband to just leave money and drive me to back to the hospital. I called the unit and told them about the error - they said 50!?!?!?!?! I said yes I will be there in 5 minutes. They changed her iv fluid to 50% dextrose and ran it at 100/hr. I stayed with her doing continuous bld sugar tests until midnight. Her BLOOD SUGAR never dropped below 8.1 - in Canada (Ontario) normal blood sugar levels are between 3 and 7.

I was praised and praised for coming back and admitting my mistake. I haven't worked as an RN since.

You did good. You made a mistake -- I don't know anyone who hasn't -- but then you realized that you made a mistake and rather than try to cover it up, you did absolutley everything you could to rectify it. Your patient did OK, and you were responsible for that every bit as much as you were for the mistake.

Patients are amazingly resilient, and can survive mistakes we make if we realize our error, admit it immediately, and do everything we possibly can to correct it. Which you did. You are to be commended for that.

Ruby Vee, who has made numerous errors and seen numerous more in 26 years of nursing!

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the reason that we were given that the assisstant nurse manager lost her license also is because she was charging, and as you know if you charge, you are held accountable for all pts.:o

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Accidently Set Mso4 Pca For 1:1 Mix And The Syringe Was A 5:1 Mix And The Pump Was Running At 5 Mg/hr (that's 50 Mg An Hour For You Tired Soles) Luckily The Patient Had Been Receiving High Dose Morphine For A Long Time With His Burns And There Was No Major Repocussions. It Did Lead To My Action Of Getting The Pump Company To Put In A New Program To Ask The Rn To Double Check Settings As They Were Being Put In Place. All Our Pumps Now Have An External Bright Sticker Stating 5:1 Mix When Appropriate As A Gentle Reminder. Experienced And Still Learning P All Years

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My error has kept me from working since the day it happened. I so terrified that I may make another mistake which may lead to a patients crash or even death. It was a busy day and I was overwhelmed (still no excuse) and my patient was on a sliding scale insulin. I took the blood sugar and she required FIVE (5) UNITS of insulin. to this day I do not know what was going through my mind but I pulled back to FIFTY (50) UNITS instead of the minimal FIVE (5) she needed. I did my checks that it was the proper insulin. I took the patients medication profile to her bedside and compared her armband to the profile and I stated to her that I was there to administer her insulin.

Still not knowing that I had done the error I left the hospital at the end of my shift which was about 45 minutes later. I had helped her with her tray and asked her if there was anything I could do for her before I went off shift. (because sometime report & shift change take a while), she replied no.

I was at dinner with my husband at a resturant and while eating my soup, which was the first part of my meal, IT HIT ME WHAT I HAD DONE! My husband saw my face and asked me what was wrong I immediately grabbed the cell phone and tole my husband to just leave money and drive me to back to the hospital. I called the unit and told them about the error - they said 50!?!?!?!?! I said yes I will be there in 5 minutes. They changed her iv fluid to 50% dextrose and ran it at 100/hr. I stayed with her doing continuous bld sugar tests until midnight. Her BLOOD SUGAR never dropped below 8.1 - in Canada (Ontario) normal blood sugar levels are between 3 and 7.

I was praised and praised for coming back and admitting my mistake. I haven't worked as an RN since.

wow, this is so much like my biggest error. I did the exact same thing. Instead of pulling up 4 units, I drew up 40. Even when the pt said, "why is there so much in the needle?" it didn't click. Like you, it was much later in the day when out of the clear blue it hit me. I immediately called work, and they informed me that she had bottomed out, but was currently stable. I reported my error to the DON, but even with her reassurance, I lost a lot of confidence in myself.

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Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.
the reason that we were given that the assisstant nurse manager lost her license also is because she was charging, and as you know if you charge, you are held accountable for all pts.:o

Oh, she was the one who told the nurse not to wake up the patient then? I can see why now.

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it's now 2004 and my biggest mistake happened my year of graduation in 1965. this will bring back memories for all the oldsters out there and totally baffle all those recently graduated. i was working on a 60 bed public medical unit and as was common we had patients in the hall with the big o2 cylinders. it was early afternoon, the patient was in pulmonary edema, we were doing rotating tourniquets, the patient had had morphine and the doctor asked for aminiphylline to give push. our med cabinets were antiquated and i grabbed a 10cc ampoule,drew it up and with the empty ampoule in hand gave the doc the syringe and told him 10 cc of aminophylline, which he pushed in. i looked at the ampoule and saw that i had an empty 10cc ampoule ofsodium amytal in my hand. i told the doctor stat, we saw the pt was settling down, i stayed with him through the next shift and he had a great sleep. was god looking over my shoulder? undoubtedly. now 39 years later i''m still practicing but much more vigilant than that day and i think with all the inroads medicine and nursing have made, i am a much better nurse.:nurse:

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Is it always the nurse's fault when an IV infiltrates? I am a student, and just two weeks ago I was giving an antibiotic IV to a guy, my instructor was right there with me. I flushed it with saline first, which went in fine, so I started the IV and went to get the linen to change his bed with. I came back, and it had infiltrated. I shut the pump off immediately and called the IV team. About 15 cc had gone in. I didn't think this was my fault, but now after reading your posts, I am not sure.

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Well, with everyone admitting their errors, here's my worst error:

Fresh out of school in 1984, as a GN, working night shift with 15 pts (me and an aide), I had to flush all the saline locks. Back then we had boxes of hep lock flush, potassium, and benadryl on top of our med carts. Each box held about 24 sindgle doses of each med. I used to come in an draw up all my flushes to give during my first rounds..... Well I guess you can figure this out by now:crying2: :uhoh3:

As the shift ended, I realized that I had a full box of hep lock flush and I had flushed everyone with Benadryl!

:imbar

Well, everyone got a good night sleep that night anyway! I still get goosebumps thinking about that!

So glad that they have done away with that system.

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Well... I hung a Vancomycin on a pt yesterday, and accidently left the roller clamped.. so they never got it.. I hung this at 0600, and it wasn't noticed til 1530??? Whats up with that.. :)

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Thank you all so much for admitting your mistakes. I will graduate in May and am very much looking forward to starting my new nursing career. Lord knows that I will at some point make a mistake and reading about these will definitely help me to double check EVERYTHING!!! You are all an inspiration to us newbies. Thanks again.

Cyndi

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