mistakes made during your first year...

joseash · Oct 24, 2008

This is a great thread! Reading through everyone's mistakes makes me laugh only because I can relate so much. I made a med error with PO Dilaudid. I can't even remember all the details but I think I was supposed to give 4mg and ended up giving 8mg instead. My charge nurse was wonderful about it and said it was no big deal as this same lady was on a PCA pump getting a whole heck of a lot more only a day or two before so a little extra Dilaudid wouldn't hurt. When I called the doc, he just laughed and said I probably really made her happy. But still, it felt like a big deal to me and you can believe I've never made that mistake again.

Another time I forgot to take the tourniquet off my patient on my first solo IV start. My preceptor had watched me do it once (on a half out of it detox patient in restraints with bulging veins like a roadmap) so she felt comfortable with my "skills." She handed me the IV tray and sent me on my way telling me I'd be way more confident about it without her watching over my shoulder, just go on in that room and act like I know what I'm doing. It was good advice and it did work. I must be a good actress because I strutted in and acted like it was my 300th time starting an IV and as luck would have it, I got it on the first attempt. I was so excited (on the inside, calm and collected on the outside of course) that I actually got it that I completely forgot about the tourniquet! I didn't remember until I was out of the room putting away the tray. I always remember to release that right away now. :wink2:

Just the other day I took a telephone order for some Tums and wrote it down in the wrong patient's chart. I had these two ladies who looked alike and were in with similar diagnoses receiving similar treatments. Their names were totally different but that didn't stop me from mixing them up in my mind all evening. Fortunately it was only Tums and I caught on right away so it was an easy fix to call Pharmacy and re-scan on the right patient before any meds were ever sent up. After that, it must've crystallized in my mind as to who was who and I was no longer confusing the two.

Oh, and I just thought of another mistake I made. The first time I was charge nurse I forgot to do the checks on the crash cart. It occurred to me out of the blue way later after the fact. I try to squeeze that in early in the night now.

The best thing about making mistakes is you really do learn from them.

MrBubbles · Oct 24, 2008

Don't do that to yourself. I'm guessing you've been told before, you're going to make mistakes, there's just no way around it. I've screwed up too, and it tears my guts up inside. But that means I care. We worked so hard for so long to make it through school, it was brutal. But you can't question whether you belong now. It's rough, it sucks sometimes, but you'll get through it. Nurses on my unit have said that it took 3 to 6 months to get to the point where they weren't scared to death when they came in. I was floating on air, thinking how amazing it was that I am on a trauma ICU. I see the most amazing things in a level 1 trauma hospital. And then it happened, I screwed up. It totally screwed me up. Never in my life had I experienced depression or really even fear of anything. BUt I spent the next 4 or 5 days wanting to do nothing but lay in the fetal position in bed. I lost 12 pounds in 7 days. And the mistake wasn't even that big, didn't put anyone's life in danger. But I feel better every day. Every day I spend on the unit I get better, and I feel better. You will do the same. You gotta put on your game face and say I am not going to screw up, take control of yourself. RECOGNIZE WHEN SOMETHING IS WRONG AND CALL FOR HELP! Be patient, you're going to get there, It just takes time.

Ruby Vee, BSN · Oct 25, 2008

i have been on my "own" now for 1 1/2 months and was just wondering if anybody out there has made any mistakes. i have been beating myself up over some things and just wondering if anyone else has done the same?
pasha

where do i start? there was the time i flushed out the central line -- the one that had previously had the nipride drip attached . . . . how low can that blood pressure go?

there was the time i dislocated the resident's shoulder. (i'm talking house staff, not ltc resident.) to be fair, he had a seizure as i was trying to drag him in to see a patient.

there was the time i dropped the nitroglycerine bottle on the floor -- and then went to pick up glass shards with my bare hands . . . how low can my blood pressure go? low enough to pass out, it seems.

i'm sure i'll think of more.

runningtraveler · Oct 26, 2008

I flushed a GT with NS instead of H20...I know it's not really an issue but it didnt even click in my mind until several hours after I got home. I have done it 1000 times, so why would I not think to grab some sterile water to flush with instead of NS? Are GT ever flushed with NS or can this cause nausea?

Pediatric Critical Care Columnist · Oct 26, 2008

There isn't really all that much NaCl in the amount of fluid you would have used to flush that GT with to cause any noticeable changes. There's more sodium in the person's feeds. I doubt an NS flush would cause nausea either, for the same reason, unless one was to drink a bunch of it.

mama_d, BSN, RN · Oct 26, 2008

Ruby, you made me laugh...I'm very sensitive to nitro as well, as I found out after I finally figured out why I kept getting dizzy and lightheaded after my 2400 & 0600 med pass (I now use gloves when squeezing the NTP out of the little packets).

Everyone makes mistakes....just learn from them and move on. Every nurse has made plenty of mistakes in their career.

I've given wrong doses, dosed SSI based on incorrectly charted glucoses (glad that tech got fired), called the wrong doc, etc.

The one that sticks out in my mind the most is when I called a doc b/c his patient went into afib w/RVR....only to discover after I got off of the phone with him that I had misread the room number on the monitor and it was a different patient. Luckily I realized before I had written the orders in the chart (I always jot them down on my report sheet first, then recopy neatly into the chart), but I still had to call and explain what I had done. I felt like an idiot.

NurseKatie08, MSN · Oct 26, 2008

Let's see...there was the time I hung IV Vanco, was supposed to run in over 2 hours, came in about an hour after I hung it to check in, and it hadn't moved an inch...still don't know why that happened, because my preceptor and I troubleshooted the whole thing, and couldn't find a reason why it didn't get going--pump was set correctly, roller clamp was open, etc...she got it going some how, but now I am so paranoid when I have IV abx.

Then there was the time that my pt's J-tube was clogged and it exploded right in my face while I tried to flush it...yum, Jevity...

I'm sure there are more, but I can't think of them right now...

PiPhi2004 · Oct 26, 2008

One of the funniest (well it wasn't so much then) was when I was getting ready to get a pt extubated and just cut off the propofol and threw it away without letting RT know we were going to extubate this guy, not thinking about its short half-life! I just figured I could go get RT and we could get it done in a few minutes, NOT! This guy starts fighting me tooth and nail when he woke up! I literally threw myself on the guy to keep him from hurting himself and started screaming for help. We got him successfully extubated and RT just looked at me and said "Yep, bet that'll never happen to ya again!" Nope!! I felt so bad then but now I think of myself, being a pretty small girl, laying on this big guy screaming like a banchee.

I have also got sprayed with many g tube feeds by forgetting to unclamp my tubing and thinking it would just work if I tried REAL HARD to flush it. Having a face full of TF is awesome, isnt it?

I haven't done anything too serious (med errors, etc) but the little dumb stuff really made me feel like a moron for that first year. At least I can laugh about it now! :lol2:

2bnursenikki82 · Oct 27, 2008

So can I just say that I am SO glad that I'm not the only person who has endured GT spray!! I did this in ICU clinicals with a not so understanding preceptor who made me feel like a big ol' butthead.

I've given too much of a med (mixed levothryoxine so it was 1:1 in a 10cc syringe...was supposed to only give 8...gave 10!!!!!!), I've been late on meds (all the time...) and not notified a doctor when I needed to (bp changes)

But...last time I give too much or too little of a mixed meds. Last time I don't notify a doc as soon as the numbers that I don't like don't go away!

Hilinenursegrl · Oct 27, 2008

No one can top this one and I will NEVER forget it. It was sometime within the first couple weeks of my very first nursing job ever, in the ER of all places. I had an order to give IM phenergan. So I use the filter needle to draw it and then head in the room and give it to the pt, with the filter needle! I felt horrible.

Another one I did, this one on my second day and I was with my precepter, the saftey manager to boot. I was making a "banana bag", an IV of NS with vitamins added. The bag was hung and I shot the needle full of meds into the port, right out the other side and into my finger! Needless to say it was a clean needle thank god.

And the last big one was just about a month ago, Iv'e been here 6 mths now. I had an expired epi pen and was reading the directions so I could waste it. I don't know what happened but it went off, right into my thumb! My heart was racing, I was sweating, and my body was shaking. I turned out fine, but my thumb was numb and cold for a good 16 hours.

Ruby Vee, BSN · Oct 27, 2008

no one can top this one and i will never forget it. it was sometime within the first couple weeks of my very first nursing job ever, in the er of all places. i had an order to give im phenergan. so i use the filter needle to draw it and then head in the room and give it to the pt, with the filter needle! i felt horrible.

the minute you say "no one can top this one" you're lying down a challenge!

the very first im injection i ever gave was a vitamin b injection for an etoher. i went into the room with my clinical instructor, carefully explained to the patient what i was going to do, meticulously measured out the med and then identified my injection site. i darted the needle in, and was so proud of myself. then i remembered i needed to aspirate. about that time, the patient had had enough. yelling like a banshee, he jumped up out of the bed and went running down the hall, that syringe hanging out of his gluteus muscle and waving like a flag -- until it fell out. this was the days of glass tubexes -- that thing flew out of his butt and smashed on the floor. oops!

i've also had my share of tubefeeding in the face. i remember one time giving tyelenol syrup -- the cherry red stuff. i was wearing my first set of nursing whites, and that stuff went all over my face and my uniform. and my hair, my glasses and the big wigs who were visiting the hospital and taking a tour with our manager . . .

then there was my first electric bed. (yes, i've been around a long time!) i was so entranced by the idea that you just had to press a button and it went up and down. and by the iv pole that was affixed to the head of the bed. i was pushing the button and the bed went up and up and up and up . . . and the iv pole went right up with it. my fascination with the up button was forever challenged when the iv pole went up straight through the flourescent light over the bed -- the light exploded and once again, there was glass everywhere!

tryingtohaveitall · Oct 27, 2008

Ruby Vee, thanks for the chuckle at the bed and the light image. LOL!

One I didn't do but saw and also had a good laugh, a young nurse pulled the tubing out of the saline/heparin bag before deflating the pressure bag on an a-line setup. She doused the ceiling!