Your Worst Mistake

TechieNurse · May 17, 2004

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......

Hi All

Just to clarify a bit...I did end up marrying into that family, but it ended in divorce a few years later. Did this incident ever effect my relationship with my in-laws? Not sure, probably though. I never spoke to anyone about what happened, especially not the family. I didn't think it served a purpose for them to blame another son instead of me. Besides, it would only sound like I was deflecting responsibility.

I moved out of bedside nursing and am content working in Informatics. But this was the root cause of why I switched...

Thanks

KacyLynnRN · May 17, 2004

I have been an LPN for 1 1/2 years and made 2 errors...

#1. Forgot to give a pt. his 2100 dose of 60 units of Lantus insulin. Realized my error at 0230 while doing a 24 hr. chart check. I thought I was going to throw up, and felt like I was seeing double for a minute when I realized what I'd done! The RN I was working with was so sweet, she offered to call MD for me, but I wouldn't let her do it. I didn't want her to take the heat for my mistake. I checked the pt.'s BS which was 300-something, (it had been running in the 200's pretty regularly) called the Dr. on call, which I was sure I was going to get screamed at. He ended up being very nice, just have me a one time order for Humalog and told me to recheck the pt.'s BS in 2 hours, if it was >300 call him back. It wasn't. I filled out an incident report and never heard another thing about it.

#2. This was was the worst by far....I had just started working the day shift and was getting used to pt.'s being gone for procedures, etc. Had a renal pt. return from a lumbar puncture, his baseline was confused and a little drowsy, and he seemed normal (for him) then. The nursing assistant who brought him back from the procedure said, "there are some orders in his chart." I looked at the chart, it was flagged, and there was absolutely no marks on the order that anything had already been done with the orders. One of the orders stated "Dilaudid 0.5mg IV now" I double-checked the pt.'s MAR (med book or med pages) and nothing was written about any Dilaudid already being administered. I told the RN I was working with there was an order to give the pt. Dilaudid and she looked at the order as well. I gave the pt. the Dilaudid and a few minutes later, his daughter came and got me and said "my Dad looks really drowsy" I went into the room and horror of all horrors, he was drolling, unresponsive, and a quick check of his O2 sats showed he was in the 80's. Long story short, he ended up getting transferred to ICU. I was a wreck. I went home and cried all night long to my boyfriend, told him I was sure I had killed the man. At this point, I still did not realize the Dilaudid had already been given. When I returned to work the next day, my boss talked with me and told me that after I left, they called the MD and he told them the nurse upstairs assisting him with the procedure had given the Dilaudid 0.5mg! So I had actually double dosed the pt. The pt. was still in the ICU but stable. A few days after that my boss told me there had been an investigation into it, and it was determined that the nurse assisting the MD with the procedure did not follow the hospital's policies, she should have signed the order off or at least marked "given" next to the Dilaudid order so I would have known. My boss assured me over and over it was not my fault, there was no way I could have known it had already been given. The pt. ended up recovering and getting discharged. I still look back and feel guilty though, and wonder if maybe just somehow I could have figured out he had already gotten the Dilaudid once. I hope nothing like that ever happens again in my nursing career!!! :crying2:

cannoli · May 17, 2004

I agree w/ the above!
Thanks to all the nurses here for sharing their stories. My love, respect and admiration to all of us who have one of the hardest jobs in the world- nursing!
Here are by big mistakes-
Working in a busy surgical unit, I drew up a syringe of insulin for a pt (we were not allowed to take the MARs out of the book, or to take the book w/ us to the pt's bedside).
I kept getting interupted on my way to the pt's room. I had two pts in ajoining rooms w/ very similar names. I thought I could trust my memory instead of going all the way back to the nurses' station again to check the pt's name.
Well, you guessed it- I gave the insulin to the wrong pt. She was not even a diabetic.
Thankfully- it was a low dose. I felt like dirt having to tell the pt, the charge nurse and the doc what I did. BS checks q 1 hr all noc. The pt's BS didn't bottom out- she did fine w/ just orange juice w/ sugar and some crackers. I did not have to give her IV glucose. Although she was not injured, I felt really bad for interupting her sleep all noc to check her BS and make sure she was ok. She needed to rest and recover from her procedure- not be woken up all noc for BS checks! The pt did not speak english, so she was unable to tell me off in a way that I could understand.
I think I was supposed to be written up, but wasn't. This was probably due to the unit be in such a constant state of chaos, my charge nurse just forgot to do it.
Another mistake-
Hopsice inpt unit. Again, I was interupted several times on my way to give a pt her MS Contin. I was just giving it to the pt and realized it was the wrong pt. I started yelling "Spit it out! Spit it out!" I cupped my hand in front of the pt's mouth and she spit out the pill in it. The purple coating had not even started to come off of the pill, and it had only been in her mouth a second or so. Thank goodness she was a slow pill taker!
The pt was demeted so, I don't think she knew what almost happened and did not seem at all bothered when I told her "I almost gave you the wrong pill."
I did not write it up, as the med never actually entered the pt's system. I charted that the pill was wasted, due to contamination.
Here's another story I just remebered- I was working nocs at a LTC. I finished my shift and went out to a leasurely breakfast w/ my husband. I didn't get home until two hours after my shift. When I did, I found four frantic messages on my machine. I had left w/ the narc keys in my pocket.
Thankfully, there were only a couple of narcs due on days shift's first med pass. Two pts got their narcs and hour late.

That sounds like a systems problem to me. Not being allowed to take the MAR along with you!!!!! Very unsafe policy!

PMHNP10 · May 18, 2004

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....
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)

I cringed just reading your story. Like others have said, you did what you could, and I echo those sentiments. I'm sorry this affected you, because just from this story it appears you were a prudent nurse to have handled the emergency as you had (holding the neck neutral and jaw thrust). I'm glad you did stay in nursing though.

PMHNP10 · May 18, 2004

I already posted my worst mistake as a nurse, but I gotta share my story from when I was a student.

I worked at a VA which was strictly a psych facility for vets--typically I worked nights. So one morning I am just about to leave when I start to celebrate another successful night shift by whistling a little tune. It so happens that tune was "TAPS"; lemme just say it wasn't such a good idea to do so in front of this one particular Vietnam Vet sufferring from PTSD. He most certainly did not take kind to my ill-timed tune. Of course I can only assume such by the barrage of 4-letter words and threats he threw my way. :chair: Once he was finished tearing me a new cornhole, it took me a moment to figure out what happened, but once I did, I felt pretty bad because that poor guy probably heard that song far too often. I'll blame that one on sleepiness on my part. :imbar

Lesson learned: That is pretty obvious.

jerseyRN · May 18, 2004

If you had stayed home that night, the patient wouldn't have had a chance. You did your best. But unfortunately we can't control what others do (including drinking too much and falling down stairs).

Did you marry that fiance?

Dixiecup · May 18, 2004

The biggest mistake I ever made in nursing was having an affair with the Physician/Medical Director of the facility where not only did we both work but so did my husband. Of course these things always end up coming out and you can imagine the scandel. My career was totally ruined not to mention almost my life. When it was all said and done,I left and he's still there. And I learned another important lesson, the old saying is true---they never leave their wives. :angryfire

Dixiecup · May 18, 2004

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.

I can't believe the understanding and empathetic supervisors all of you have! Any place I have ever worked I've been raked over the coals, made to feel like I was an inch tall and basically been chewed up and spit out over even the smallest error! While I do believe these issues have to be addressed, it certainly doesn't help a person in an already devistated and panicky state of mind, to be further knocked to the ground by brow beating. Each of you should be thankful for your supportive superiors. :stone

Dixiecup · May 18, 2004

How humane of the hospital!

Did the student suffer any repercussions from the pressure the hospital put on the school? i.e. did they make it rougher on her to make it through the program?

nursemjb · May 18, 2004

I can't believe the understanding and empathetic supervisors all of you have! Any place I have ever worked I've been raked over the coals, made to feel like I was an inch tall and basically been chewed up and spit out over even the smallest error! While I do believe these issues have to be addressed, it certainly doesn't help a person in an already devistated and panicky state of mind, to be further knocked to the ground by brow beating. Each of you should be thankful for your supportive superiors. :stone

Dixiecup,

I know what you mean. I haven't been the benefactor of understanding supervisors either. Just a series of bad breaks. I just wish I didn't like nursing so much.

Dixiedi · May 18, 2004

It was the late '70s. I was standing at the medication cart gathering meds for whoever she was in bed 2. I don't remember names, please, it's been 30 years!

But I remember she was closest to the window, bed 2.

Anyway, the charge nurse came up and said she just got orders and asked me to give a coumadin tab to her. I said sure, just pop it in the cup.

She did.

I gave the meds to her and finished my 4 o'clocks on down the hall.

I had several newq admissions that day and had a lot of admin charting to get done.

I went to the station, sat down with my stack of charts and proceeded to confirm, fill in and finalize the admin orders.

To my horror I found the charge nurse had asked me to give the coumadin to the wrong patient!

Luckily, a little Vitamin K was all that was needed since the wrong lady had excellent labs. But, the potential was absolutely flabbergasting at what that error could have been. Never again have I ever given a new med without first seeing the order.

It still gives me the creepy crawlies to think I gave a med, any med, to the wrong pt because I believed another nurse had done the verifying for me! Never again!

Brenda-RN,BSN, WA. · May 18, 2004

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!

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.