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.

Hi everyone,

I haven't been the boards for a while (been really busy finishing semester 3 out of 4) but found this topic appropriate for me to post in since I have come to the realization that I may have made a mistake this week in clinical. :(

Well basically, a patient I had was scheduled for insulin NPH at 1730 with her dinner and I was so focused on just giving all my patients their regularly scheduled medications since I had to get all new patients in a hurry - about an hour before I started patient care (my other patients were discharged from the previous day). Well, now that I think back on it, I think my patient probably had a sliding scale insulin for regular in her PRN list of meds and when I checked her blood sugar before dinner, it was 230! So I'm thinking to myself "HELLO!!! Why didn't you think that with a BS of 230 that your patient would need some regular insulin coverage for her dinner!!!"

I feel ABSOLUTELY scared right now. I'm thinking I should probably confess this to my instructor (regardless if the patient is still okay and even if no one were to find out)and go visit the hospital tomorrow to make sure my patient is okay. I hope I didn't hurt her or do anything worse ... :(

I feel really dumb right now. I don't even want to tell any of my nursing friends because they'll think I'm going to make an awful nurse if I can't even do something so simple as to give insulin.

Thank you everyone for letting me vent and also for sharing your mistakes as well. I know we're all human but I just feel like I need to be really "on top" of things if I want to be a good nurse.

#1 It's too late to do it now so don't go and confess.... just remember it for the future.

#2 It's better for the blood sugar to be a little high than too low.

#3 In the future if you make a mistake like this just take the patients blood sugar again in 30 minutes and prior to their next meal or bedtime.

#1 It's too late to do it now so don't go and confess.... just remember it for the future.

#2 It's better for the blood sugar to be a little high than too low.

#3 In the future if you make a mistake like this just take the patients blood sugar again in 30 minutes and prior to their next meal or bedtime.

Thank you for the reassurance. I was also thinking that too high is better than too low but I just needed to hear that from someone else, especially from a "real" nurse with experience.

The more I think about making a mistake, the more I start feeling back and am actually crying right now because I feel so bad. :o

As for the confessing part, I still feel a need to do this for reasons of being a responsible nurse and taking accountability for my actions. The way I think of it... is it would look better to if I tell my instructor what I did and if she were to find out that would be a lot better than if I didn't tell her, and her thinking that I think I did nothing wrong, and then her finding out. Did that make sense?

Thank you so much for listening. I really need all the comments and advice I can get (good or bad). I appreciate them all.

Hi everyone,

I haven't been the boards for a while (been really busy finishing semester 3 out of 4) but found this topic appropriate for me to post in since I have come to the realization that I may have made a mistake this week in clinical. :(

Well basically, a patient I had was scheduled for insulin NPH at 1730 with her dinner and I was so focused on just giving all my patients their regularly scheduled medications since I had to get all new patients in a hurry - about an hour before I started patient care (my other patients were discharged from the previous day). Well, now that I think back on it, I think my patient probably had a sliding scale insulin for regular in her PRN list of meds and when I checked her blood sugar before dinner, it was 230! So I'm thinking to myself "HELLO!!! Why didn't you think that with a BS of 230 that your patient would need some regular insulin coverage for her dinner!!!"

I feel ABSOLUTELY scared right now. I'm thinking I should probably confess this to my instructor (regardless if the patient is still okay and even if no one were to find out)and go visit the hospital tomorrow to make sure my patient is okay. I hope I didn't hurt her or do anything worse ... :(

I feel really dumb right now. I don't even want to tell any of my nursing friends because they'll think I'm going to make an awful nurse if I can't even do something so simple as to give insulin.

Thank you everyone for letting me vent and also for sharing your mistakes as well. I know we're all human but I just feel like I need to be really "on top" of things if I want to be a good nurse.

Did you write it down anywhere? If not, I still think it would be better to keep it on the QT. You can't change it now it's been too many hours.

A little less insulin is better than too much. I've had many more problems in my 12 years of nursing with patients bottoming out on blood sugars than elevated ones. The last one wasn't my patient but I helped a nurse recently with a patient who had a BS of 35. Let me tell you it was scary......

The scariest for me was a student in middle school who didn't take her diabetes seriously and varied between the 40's to the 600's......now that was no fun at all.

Keep your chin up......you can write back again and I'll answer.

Did you write it down anywhere? If not, I still think it would be better to keep it on the QT. You can't change it now it's been too many hours.

A little less insulin is better than too much. I've had many more problems in my 12 years of nursing with patients bottoming out on blood sugars than elevated ones. The last one wasn't my patient but I helped a nurse recently with a patient who had a BS of 35. Let me tell you it was scary......

The scariest for me was a student in middle school who didn't take her diabetes seriously and varied between the 40's to the 600's......now that was no fun at all.

Keep your chin up......you can write back again and I'll answer.

Yeah, blood sugars that low would be scary for me too. So I take it that you're either a school nurse or a pediactric nurse? (Am I way off?)

Well the fact is that I did chart it (both on paper and in the computer), under my own name/login, so there's no way around that. But I had really communicated with my nurse that evening and am sure I told her what the blood sugar was. I guess it never came up in her mind to remind me about checking for sliding scale coverage either - which I know is still no excuse for my mistake. I can't blame anyone but myself.

I just hope I don't get kicked out of my program (which I don't think will happen because another student actually had a med error, involving Dig, and that particular student is still in the program, she just got a "write-up" sort of thing).

Thanks again. I'm starting to feel a little better.

Yeah, blood sugars that low would be scary for me too. So I take it that you're either a school nurse or a pediactric nurse? (Am I way off?)

Well the fact is that I did chart it (both on paper and in the computer), under my own name/login, so there's no way around that. But I had really communicated with my nurse that evening and am sure I told her what the blood sugar was. I guess it never came up in her mind to remind me about checking for sliding scale coverage either - which I know is still no excuse for my mistake. I can't blame anyone but myself.

I just hope I don't get kicked out of my program (which I don't think will happen because another student actually had a med error, involving Dig, and that particular student is still in the program, she just got a "write-up" sort of thing).

In my 12+ years of nursing I've worked in the OR (adult and pediatric), home health, med-surg, rehab (both kinds), ortho-neuro, oncology, telemetry, PCU, SNU, special procedures, and school nursing. Most of my hospital nursing has been per diem for a nursing agency.

Before I was a nurse I worked as an engineer in the Materials and Processes Lab at General Dynamics. I did research and development for all materials used on the F-16 aircraft.

Oh boy, nursemjb, you weren't kidding when you said "precious." Little William is absolutely adorable. In one of the pictures he looks like a little doll with his big blue eyes, pink lips, and all that nice hair. What a little cutie!

:)

I have a little one of my own. He's three going on four in August (don't have any pics on the computer at the moment). Looking at your grandson's pictures makes me want to have my second one because at my son's age, they begin to lose those cute baby features (i.e. nice big round cheeks, and big bright eyes). How old is little William Gabriel?

Oops! nevermind about his age. I just remembered that his birthdate is on the web site. So he'll be turning three this November - enjoy all the "baby-ness" now while it's still there!

Oops! nevermind about his age. I just remembered that his birthdate is on the web site. So he'll be turning three this November - enjoy all the "baby-ness" now while it's still there!

The only bad thing is that he lives so far away from me. I haven't seen him since Christmas. Both of his parents are in the military......

Where do you live? How old are you?

My first mistake as a nurse was deciding to work 2nd shift (3-11p) its the shift with no life.

Seriously. I made three mistakes in a 24h period.

#1: I gave 3mg of dilaudid when the order said 2mg. By God's grace the

pt wanted the dosage increase and the doctor increased it to 3mg that

day.

#2: That same pt I initiated the pca for dilaudid and entered the

concentration as 1mg/ml instead of 0.2mg/ml = the pt got 1/5 of the

order dose. (3 nurses checked it that day was well)

#3: This one upset me more...the pt was in a rush to be dc'd home...I

failed to remove his IV assess/hep-lock.

This happened 15 years ago and it has haunted me so much, I left bedside nursing and went into other areas (utilization review, case mgmnt. etc)

I had been a nurse only 2 years and had been working in med-surg/stroke unit. I was off duty, at a birthday party. Most of the guests were in their early twenties and there was drinking going on. The host (the brother of my fiance) had an unwitnessed fall down a flight of stairs. My fiance found him and called for me. I took charge of the situation, instructing others to call 911, checking airway/breathing/circulation etc. I suspected he had a broken neck, but he had a faint pulse and was breathing. So, kneeling at his head, I stabilized his head/neck between my knees and lifted his jaw with my fingers to keep his airway open (jaw thrust maneuver) and kept re-assessing him, waiting for the EMTs to arrive. Well, to his family, it didn't look like I was "helping" him enough. I had hysterical family and friends in various stages of drunkeness (I had had less than one drink) and then, the worst happened....one of his brothers, crying that I wasn't doing anything (with others agreeing), pushed me out of the way and tilted the victim's head back (hand on victim's forehead, other hand on victims jaw) to listen for breath sounds/initiate CPR. I can still hear the bones in his neck crack when I remember that.

Of course, then he became pulseless and breathless and needed CPR. So, to the family, I wasn't doing anything. Luckily, the EMTs arrived right after that but he was DOA when he arrived at the hospital.

I still carry a lot of guilt about that situation; the "if only" syndrome....:crying2:

It crushed my self confidence and my belief in my skills.

Someone died and I could've/should've prevented it.

Unfortunately, there's no rectifying this situation. There's no remedy, no counter-action to take. A young man is dead and only I know all the details of what happened. I pray for forgiveness daily.

I hope that by sharing this, others will

1) be cautious at all times, both on and off duty. You may be called upon to help in emergency situations

and

2) if you decide to take charge of a situation, be assertive/aggressive and don't let non-medical bystanders interfere (by imitating what they've seen on TV)

Specializes in LTC,Hospice/palliative care,acute care.
This happened 15 years ago and it has haunted me so much, I left bedside nursing and went into other areas (utilization review, case mgmnt. etc)

I had been a nurse only 2 years and had been working in med-surg/stroke unit. I was off duty, at a birthday party. Most of the guests were in their early twenties and there was drinking going on. The host (the brother of my fiance) had an unwitnessed fall down a flight of stairs. My fiance found him and called for me. I took charge of the situation, instructing others to call 911, checking airway/breathing/circulation etc. I suspected he had a broken neck, but he had a faint pulse and was breathing. So, kneeling at his head, I stabilized his head/neck between my knees and lifted his jaw with my fingers to keep his airway open (jaw thrust maneuver) and kept re-assessing him, waiting for the EMTs to arrive. Well, to his family, it didn't look like I was "helping" him enough. I had hysterical family and friends in various stages of drunkeness (I had had less than one drink) and then, the worst happened....one of his brothers, crying that I wasn't doing anything (with others agreeing), pushed me out of the way and tilted the victim's head back (hand on victim's forehead, other hand on victims jaw) to listen for breath sounds/initiate CPR. I can still hear the bones in his neck crack when I remember that.

Of course, then he became pulseless and breathless and needed CPR. So, to the family, I wasn't doing anything. Luckily, the EMTs arrived right after that but he was DOA when he arrived at the hospital.

I still carry a lot of guilt about that situation; the "if only" syndrome....:crying2:

It crushed my self confidence and my belief in my skills.

Someone died and I could've/should've prevented it.

Unfortunately, there's no rectifying this situation. There's no remedy, no counter-action to take. A young man is dead and only I know all the details of what happened. I pray for forgiveness daily.

I hope that by sharing this, others will

1) be cautious at all times, both on and off duty. You may be called upon to help in emergency situations

and

2) if you decide to take charge of a situation, be assertive/aggressive and don't let non-medical bystanders interfere (by imitating what they've seen on TV)

The first rule of emergency medical services is to secure the scene-their safety is paramount.You could have gotten hurt yourself had you tried to be more assertive

.You have NOTHING to be forgiven for-you were surrounded by drunks and you did all you could have done.Had you resisted the brother's attempt to help he would have smacked you flat.ETOH and the brother killed the victim-not you...As for the rest of the family do they blame you? Has it affected your marriage? You can go back and get the proof you need to clear yourself of blame but is it worth it?Will it cause more harm to all involved? I am betting the brother does know what he did-why not talk to him with your husbands help? Have you ever gotten counseling ? I think you should...You did all that you could and you have to believe that before you can heal yourself......

The first rule of emergency medical services is to secure the scene-their safety is paramount.You could have gotten hurt yourself had you tried to be more assertive

.You have NOTHING to be forgiven for-you were surrounded by drunks and you did all you could have done.Had you resisted the brother's attempt to help he would have smacked you flat.ETOH and the brother killed the victim-not you...As for the rest of the family do they blame you? Has it affected your marriage? You can go back and get the proof you need to clear yourself of blame but is it worth it?Will it cause more harm to all involved? I am betting the brother does know what he did-why not talk to him with your husbands help? Have you ever gotten counseling ? I think you should...You did all that you could and you have to believe that before you can heal yourself......

I agree with ktwlpn, you did what you could. There are so many sad/tragic situations exacerbated by alcohol.......I think grief counseling would help you.....

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