Made a nursing judgement error- any horrible stories to share?

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that you lived through and still kept your license?

Last night was horrible. I work the 11-7 shift and I'm a fairly new nurse (about a year of full time work) Anyway, I brushed off a patients symptoms as "normal" for his dying/disease process and that is apparently the WRONG thing to do. He had an order for suctioning PRN and had been gurgling for many days now~ it was my first time on that hall and my 2nd day back at this facility after originally quitting for other reasons. I know the nurse the previous night had to suction him and was nervous because the daughter was in the room. Last night, I didn't think anything of the gurgling. I suctioned but he fought so I stopped, I attemped a neb but he took off the mask. I sat him up higher and turned down the air and he almost yanks out his g-tube. He is/was on hospice support but was not a DNR. I didn't think his condition was any worse really so I didn't act on it. The patient went from groaning and combative early in the night and trying to yank out his g-tube (all common things for him) with stable VS to respiratiory distress by the end of the shift and an O2 sat of 2.. yes 2. The nursing superv walked in to find him and called for a crash cart because he had so much discharge coming from his mouth. I had just finished a crazy med pass that I started at 5 but had only taken a 7 minute lunch because the rest of the night was filled with pt drama. I didn't check on him during my medpass and that's when it got even worse.

*** He had orders for everything from anxiety to restlessness to sleeping to excess secretions ect***

I feel useless and like a failure for letting the facility and my peers down as well at this man and his family (that I couldn't get a hold because both numbers were disconnected). I feel like I'll be the "talk" of the facility for the next few weeks and there will always be those who lie or make themselves appear better to make me seem 100% incompetent. I don't want to show my face there again but I have 3 more days this week. I don't want to lose my nursing license and I don't want the CNA's to lose trust in me as a nurse. I'm really beating myself up over this but you can bet I'd never make that same mistake again.

Who knows if the hospital can save him now? I sure don't.

Any words of wisdom or stories to share so I don't feel alone in my lack of nursing experience?

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We all make mistakes, the trick is to learn by them, admit what you could have done different and go on from there to be the best nurse you are able, others will see that also. With simple hospice support and "making as comfortable as possible" I can see your reaction. I am very confused though on the hospice support with no DNR?

I once started chest compressions on a woman and the first push heard/felt two cracks just KNOWING I had cracked ribs. That was a very tense moment and I felt like just stopping right there! She was sent to the unit after coding and I talked to the doctor, come to find out she had CPR done before this time and the ribs had broken then. I felt sorry for the woman, she did live..but the overiding feeling was relief.

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I'm confused too. Sometimes that happens :)

If someone is on hospice and you feel like they are out of sorts or giving you alot of problems or need more care, call them. They should send in a nurse and asses the pt and stay for a while to help get them comfortable.

Think about what you could do differently next time. If it was really busy, could you called your supervisor to help? When you have 20, 30+ residents to take care of, sometimes is it those one or two critical that can take up the time and get everything pushed back.

If someone is full code, don't seem right etc..most often..they are going out to the hospital. In a perfect world, yes...they should or could stay in a ltc and get just about the same that they would in the hospital, but not if I have 20+ other pts to take care of.

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I love how everyone here is so supportive and understanding. It could be any nurse in that situation and everyone has provided such great advice. :) I can't wait to start school.

From an un-nursely perspective, everyone has those moments. We just need to grow in learn from them. It won't be your last mistake because that is the only way we truly learn and reinforce those principles. Good luck!

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Specializes in tele, oncology.

Two true stories that happened on my floor...

I was caring for an agitated, combative, little old lady (weighed about 85 lbs, about 93 y/o) who was in with afib with RVR. We had her rate controlled to the 120's baseline but when she got worked up she'd hit the 160's. I explained this very clearly to the day nurse. I also explained that POA was refusing a central line, all we had was a 22 in her hand, and to be very gentle with it, even with flushes, b/c it wasn't going to last long. I came back two nights later and found out that the nurse I reported off to gave her lopressor IV fast push for a HR in the 140's while she was combative and they ended up coding her less than two minutes later. She didn't make it. That nurse still works our floor.

We had a nurse who knew it all b/c he had been an EMT prior to getting his nursing license...as a LPN, he even did his own pushes despite being told numerous times that it was outside his scope of practice. He bolused an entire bottle of amiodarone over a couple of hours, after having given the loading dose as well, and didn't even think twice when he couldn't find a pressure on the man...didn't call the docs or notify the charge or anything. The patient ended up being okay, but nights had a heck of a time trying to clean up the mess. The nurse ended up getting unrelated felony criminal charges against him and hopefully that means that he'll lose his license. But he continued to work there for quite a while as well.

Those are the two worst stories I can think of to share with you. Both were labeled "learning opportunities" by our management.

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Thanks for the replies! He is on hospice support which is just he;ping stay comfortable but he remained a full code (although they were attempting to get a DNR.) I just feel like a fool and now that I look back, I should have done more and I think "duh" why didn't I think of that? I sure hope I'm not the joke around there :-/

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Specializes in Triage, MedSurg, MomBaby, Peds, HH.

The more I get my feet wet in my program, the more I truly admire each and every nurse in practice. It's a HARD JOB. You're only human and mistakes will be made.

Hold your head high, CrazyFLbean. There's not a nurse at your facility who hasn't made some sort of error at one time or another. Just use the experience to make you a better nurse.

HUGS to you -- I know this is on your heart and troubling to you. Hopefully you will soon feel some peace.

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Specializes in ICU/ER.

an O2 sat of 2? are you sure the prob was even on?

Sorry you had a bad night~~SOME times I equate Med Surg nursing to assembly line nursing. As long as mgmt keeps the nurse to patient ratio high things like this will happen.

I am only guessing you didnt have a CNA to help you, the other nurses on your floor were prob just as busy. It is very easy for mgmt to come in the next day and point out all your errors, but where were they when you had 3 bathroom lights going off at once and an angry family member demanding a warm blanket for thier mom?? and a 30 year old man complaining for 10min because your hospital doesnt have CNN as a channel choice. And a confused pt who pulled thier IV out 3x ...

The list never ends....

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not all hospice pts are DNR, its not longer a requirment

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I agree, so long as you learn from this. Everyone is still learning, no matter how years experience you have. I have seen seasoned nurses make big mistakes. Sometimes we have to learn things the hard way. Unfortunately. Dont be so hard on yourself. I have had my fair share of mistakes and I have learned from them and will NEVER make the same mistake again. I also tell others of my experience so they dont have to go through it as well. A lot of the times its things that they could have easily done. Next time you have a pt. that you feel iffy about, keep a watchful eye on them, and ask others for help to do your med pass. I had a critical pt the other day with a temp of 39 C post blood transfusion and the MD suspected he was becoming septic. I had to do a bunch of blood work stat and hang IV antibiotics stat, during my med pass, and I asked a colleague for help and she took care of my other pts for the next little while. Your never alone.

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Thanks for the replies! He is on hospice support which is just he;ping stay comfortable but he remained a full code (although they were attempting to get a DNR.) I just feel like a fool and now that I look back, I should have done more and I think "duh" why didn't I think of that? I sure hope I'm not the joke around there :-/

You were probably overwhelmed with all that you had to do. If these places would staff better there would probably be a lot less of these types of things happening.

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Specializes in Gerontology, Med surg, Home Health.

I don't think anything you did or didn't do could cost you your license. You attempted to suction and he refused. Were you absent the day they taught fortune telling in nursing school? We all make mistakes and hind sight is ,as they say, 20/20. Lesson to be learned...if you have a big floor with a hard med pass and one patient needs extra attention--call your supervisor. Most of the patients take way too many meds and most of them wouldn't be harmed by missing any or getting them late. Sometimes you just have to prioritize your tasks. Don't beat yourself up over this please.

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