MIstakes New nurses MAke?

nurseprnRN, BSN, RN · Nov 6, 2011

the worst thing that happened to me as a new grad was the day i got a lady with fresh postop carotid endarterectomy whose bp was too high. the chief of surgery was right there and told the intern (what we now call an r1) to give a medication called apresoline iv push stat to drop her pressure to safer levels, to avoid rupturing her carotid, and to repeat it q5minutes until her pressure was under control. it wasn't a familiar medication to me, but i figured the chief of surgery oughta know so i went and got it out of the drawer and gave the first dose, the intern at my side. five minutes later, pressure is still too high. intern says, give it again, so i did. same thing five minutes after that. and at twenty minutes.

and then her bp went down. and down. and down, and down, and down, and the woman who was awake and talking to us after her elective endarterectomy drowsed off and went to sleep. and she never woke up again, because we dropped her bp so far she stroked out.

chief of surgery denied ever having said any such thing :mad: and hung the intern out to dry, which was devastating to him. i was finally able to go look it up and learned that the peak effect of iv apresoline can be 30 minutes after the dose :eek: , so of course we gave her waaaaayy too much. i was devastated.

moral of the story was that i learned never to give anything, even in an emergency, that i didn't know about. if i had no time to look it up, i would hand it to the md or someone else to give. of course, in time i knew all the emergency drugs, and that became a moot point, but still.

sometimes i still see that woman in my dreams, and it's been almost, good grief, forty years. :crying2:

BeachsideNic · Nov 7, 2011

Wow... That's a story inspiring enough to instill that point into me forever as I begin nursing school... I will never give anything to anyone unless I know exactly what it is going to do... no matter who told me to do it. Thanx for sharing that.

chevyv, BSN, RN · Nov 7, 2011

The one big huge mistake I made was actually less than 1 yr ago. I work in a county psych facility and was dealing with a volatale situation. I had security helping but needed to get a med IM into a pt quickly. I was on hold waiting for a doc to come to the phone and was charting (we have paper charts) while waiting. Doc comes on, I explain situation, and give the pts age and weight. I finally get the order and draw it up. Everyone is upset because it was taking so long. I'm just trying to hurry. I administer the med and got this feeling. I check the chart and read the allergies and sure enough there is the med I just gave listed under allergies.

Allergies are listed everywhere in the chart except the nurses notes. I had to call back, get another order for a med to counteract the one I just gave, and write up an incident report. I couldn't believe that I had done that. I have never been so scared. Turns out the allergy wasn't really an allergy but doesn't matter it was listed as such and I screwed up.

I let the fact that all hell was breaking loose, the potential for injury was high, and I was getting comfortable in my nursing role (too comfortable) by charting while on hold to save some time. I never would have thought I would make that error. I tell all of the new nurses so they don't make the same mistake. Most look at me like they can't believe anyone could make that error. Stepping up and realizing I could get fired was nothing compared to losing a life. Thankfully, I didn't get fired, but it was a mistake I will never make again.

PMFB-RN, RN · Nov 7, 2011

the chief of surgery was right there and told the intern (what we now call an r1) to give a medication called apresoline iv push stat to drop her pressure to safer levels, to avoid rupturing her carotid, and to repeat it q5minutes until her pressure was under control. it wasn't a familiar medication to me, but i figured the chief of surgery oughta know
moral of the story was that i learned never to give anything, even in an emergency, that i didn't know about. if i had no time to look it up, i would hand it to the md or someone else to give.

*** there are two, maybe three morals to the story. you learned one. another one is that very, very often physicians really do not understand much about drugs and you can't trust them to know all they should about iv drugs. except for anestesia, physicians are not really trained in medciation administration, nurses are. also i never allow a physician, except anestesia, to give my patient medications, unless it is a learning lesson for a resident and i am standing by and directing him/her. another moral is the a physician will hang a resident or nurse (especialy a nurse) out to dry if it means they avoid looking bad. i have had several physicians tell out right lies so that i would get the blame instead of them.

Ruby Vee, BSN · Nov 7, 2011

i often see new nurses who don't know something -- but think they ought to -- asking other new nurses for advice. the second new nurse doesn't know either, but wants to be helpful, so she gives an answer that may or may not be correct. i've seen this happen over and over. once it was with giving 5 mg. (yes, i mean five milligrams) of digoxin -- seems like having to draw up ten vials would have been a clue.

i wasn't a new nurse, but i was on orientation in a new job, and my preceptor was at lunch when another nurse approached me to check blood with him. he had the patient's addressograph plate in his hand, and wanted to check the blood right there, standing in the hallway. i refused. he said, and i quote "we always do it this way. i don't want to bother the anyone in the room." i told him i'd be happy to check blood with him in the patient's room and against her name band. otherwise no, i wouldn't check blood with him. although he was clearly upset with me, we did it my way. the next morning, we heard that the patient we'd transfused had had a transfusion reaction and died. in a panic, i asked if it was the unit of blood i had checked. it seems that it wasn't. when it came time to hang the next unit of blood, the male nurse had gone to another newer nurse who agreed to check blood in the hall against the addressograph plate. they gave mrs. richards blood to mrs. thomas. (or was it green's to browns? or hanson's to handleson?) then they gave mrs. thomas' blood to mrs. richards, who fortunately, survived the experience.

another time, two brand new nurses took a central line out of a patient sitting in a chair. when i found out, i attempted to educated the new nurse who had removed the central line. "abbie said it was ok," she said, referring to a brand new nurse who only barely made it off of orientation and probably should not have. the worst part was, she continued to insist that it was ok because abbie says it was rather than listen to me (30-some years of experience) or read the actual policy. they're both gone now -- got accepted to crna school. i shudder to think . . . .

MorningLight · Nov 7, 2011

Here is an informative website with true stories of medical errors:

http://www.webmm.ahrq.gov/cases.aspx

You can learn a lot from these cases!

MorningLight · Nov 7, 2011

I am a new nurse, graduating in December, and I have already seen many things I don't agree with. If I was a patient, I would be scared to stay in most hospitals. I plan on doing all procedures according to hospital policy, even printing the policies to take with me to the bedside if needed, until I get them down. If I end up working on a unit that doesn't respect patient safety, transparency, and teamwork, then I will gladly move on to somewhere else!

allnurses Guide · Nov 7, 2011

I am graduating in December and these stories scare the bejeezus out of me.

chevyv, BSN, RN · Nov 8, 2011

They should not scare you. You should learn from them. I get the whole policy thing, but wait until you see the policy and procedure books. We have 3 huge binders! 3!!!!! There is no way to get through them all especially during an emergency type situation. We all would love to work in a team centered environment, unfortunately, it isn't always the real world and jobs are so scarce right now. You do the very best you can, understand you will make mistakes. No doubt about it. Learn and continue to learn. There isn't a day that goes by that I don't learn something and I've been a RN for just over a year now. I still feel awful for the med error I made. I take care of that pt everyday I work and you better believe that whenever things get crazy, I take my time and am very sure of my meds.

ad3vans · Nov 8, 2011

Thank you everyone for your stories. Ill be using them as examples in my papers presentation. :) all the stories make me super nervous to be a new nurse!

DOU RN · Nov 26, 2011

I had an order to give Bactrim 500 cc iv over an hour. The pharmacy sent me a 500cc bag with the bactrim label printed out and place on the bag. I looked through from the other side and saw the printing on the premixed bag itself showed it actually was a bag of Heparin. I called the Pharmacy and they, of course, came right up and took the bag and evidence away with them. Moral---- I don't care how it's labeled. look to make sure it is still the right med in the bag.