Mistakes we have made

[LilpoRN]

I think it would be beneficial to us all to share stories of mistakes we have personally made, or almost made, or stories we have heard or seen of other nurses making mistakes. I don't know about all of you, but I know I learn best from mistakes. Something about that scare tactic drills the lesson in a little deeper than if someone was just to say "next time you should do it this way". I'm a brand new RN so fortunately I personally don't have any stories, but I have heard some good ones from experieneced RN's. I am off orientation in two weeks, so since I've been an RN I've always had someone double checking everything. I did have one close one though.

Our patient was taken to OR right before shift change. He was also a new admit from ER for Auto ped accident. In report we heard his lactate was high and his blood pressure was on the soft side. They had tried getting access but he was a hard stick, they even used the site rite ultra sound machine to try to get a peripheral and had no luck. He had one IV the paramedics had managed to get. His electrolytes were also thrown off. Phos was low, K was a little low, and he was going to need calcium. So we knew he was going to need some fluid resusitation and more than one IV for access. Anesthesia had said they would put a central line in our patient while he was in OR.

Patient is in OR and I started pondering the idea of what if he comes back really sick from OR. I asked my preceptor and the other nurses in our pod what they would do if he comes back unstable.Say they get the central line in but no chest x-ray had been done yet to verify. We know he is a hard stick, say our efforst are just as bad. Would they go ahead and use the central line before verification? Everyone agreed, if he was unstable enough YES they would use the central line.

Patient comes back from OR, Line is in, vital signs appear stable and he still has vecuronium on board so he isn't moving anything. I look at his central line to transduce a CVP from and there is a wierd dead ender on it, my preceptor recognized it to be the hub of the wire they had totally forgotten to pull out and she took it out. A fair amount of blood came out but we didn't think too much of it, we hooked up the CVP and a huge wave form appeard. It was definitely an arterial wave form. Chest x-ray by this time had been up and gotten verification of placement. It was in the CAROTID ARTERY! The doctors immediately came to bedside to pull it out and the patient fortunately didn't stroke from it and ended up being fine, but it was scary to think we had all talked about transfusing something through that line if need be. To think if we had given anything through there it would have gone straight to his brain.

Lesson for me learned is never trust any line placement until it at least has been transduced. But ALWAYS get chest x-ray first.

Your turn to share

[07302003, ASN, RN]

Med errors as a new nurse -

Gave dilaudid 2mg instead of 1mg out of a 2 mg syringe (no harm to patient)

Gave entire glass container of methyprednisone IV (40? 100?) instead of looking at the med order to carefully measure ML. (no harm to patient)

Med errors are common and unfortunately it's trial by error. Crikey. No wonder I hate the thought of being hospitalized.

[ShelleyERgirl, LPN]

Geez, how long have ya got? Once gave a recruit a bicillin shot without putting it in the tubex first so I could push it in, that was fun.... Can I get a big "DUH"?:doh::smackingf

[nerdtonurse?, BSN, RN]

I once had a transfer in from a NH, oriented to name only and barely that, very, very, very long psych history. Obviously incapable of giving consent....and when I happened to glance at that page in the chart (usually that's an admission thing, we don't check it as part of our chart checks)....found out we'd been treating a woman for 3 days with no legal authority to touch her. I mean, I'd been giving meds, doing treatments, etc., and had absolutely no authority to do anything.

I nearly peed my pants, and RAN to the admin rep. The lady had put down the names of her alternate personalities as her NOK, POA, on her nursing home info, and it took another 2 days to find this woman's actual family, who didn't know where she was, or even that she was in the hospital. All I could think was, "Oh, lord, if she dies, what are we going to do with her?" followed by, "and what if some nutcase relative shows up, yelling 'you killed grandma!' and wants to sue me?"

[Spritenurse1210, BSN, RN]

As a new nurse I had a lady who was to get half of a 1mg tablet of valium and I gave her a whole tablet. No harm came to the resident and my preceptor had pointed out that she also gets half a tablet prn! Lol. Needless to say she wasn't on the floor that night! (She had a habit of pulling out her g tubes and throwing herself on the floor when she had her anxiety attacks)

[Penelope_Pitstop, BSN, RN]

pull up a chair.

~ i wasn't familiar with plum pumps and infused venofer wide open...patient's bp dropped a bit but otherwise he was okay.

~ on my medsurg floor, blood was hung on the wrong patient...yet documentation shows that protocol was followed in regards to identification. not sure how...thankfully patient was okay and the other patient received her blood soon afterwards.

~ after report, i went in and assessed a patient who wasn't mine (i also flushed his iv, told him my name, checked his montor, etc.) i realized my mistake when i counted my patients and came up with too many!

~ i had two patients who needed ivp drugs, so i drew up each one in a different syringe. problem? i didn't label either syringe. so i had to go back and do it again. from then on, i did one patient's meds at a time, and always labeled, along with time/date/initial and drug!

~ an order was made for a patient with an exceptionally high fall risk to have a low bed. no one ever sent the order to the bed company, and this lady was with us for weeks, until someone said "my gosh, why doesn't she have a low bed?" and found the order.

~ the low-bed-needing patient was only a patient of mine because of a huge error. during an er visit for yet another case of dka, an ij was started, but ended up occluding an artery and causing a massive stroke. she was in her 20s, a mom and seriously brain injured, required a trach, tube feeds, and atc care...she came in from the nursing home because of a mess of metabolic issues.

~ i had the misfortune of discovering that the guidewire to my patient's dht was in place hours after surgery and x-ray verification. the thing is, the nurse before me claimed she'd adminstered a med through it.

~ one of my patients was actually resting for once (i think she'd tired herself out after days of not sleeping) and was agreeable throughout her assessment, so i disturbed her as little as possible. i thought i was doing her a favor, but her iv of clindamix ended up infusing. whoops.

~ there was a patient receiving sc heparin tid who hadn't received coag studies for a looooong time and was actually bleeding from her fingertips. on of the nurses on my floor adminstered her 0800 & 1600 despite this finding. that was a bloody mess for the 1900 shift to find...literally. she died a few days later.

~ i had a patient in 2-pts who was ridiculously combative. i was talking to him and bent over his bed. the last thing i remember was a shin coming up towards my forehead. then i opened my eyes and saw the ceiling.

*~jess~*

[ShelleyERgirl, LPN]

I once had a transfer in from a NH, oriented to name only and barely that, very, very, very long psych history. Obviously incapable of giving consent....and when I happened to glance at that page in the chart (usually that's an admission thing, we don't check it as part of our chart checks)....found out we'd been treating a woman for 3 days with no legal authority to touch her. I mean, I'd been giving meds, doing treatments, etc., and had absolutely no authority to do anything.

I nearly peed my pants, and RAN to the admin rep. The lady had put down the names of her alternate personalities as her NOK, POA, on her nursing home info, and it took another 2 days to find this woman's actual family, who didn't know where she was, or even that she was in the hospital. All I could think was, "Oh, lord, if she dies, what are we going to do with her?" followed by, "and what if some nutcase relative shows up, yelling 'you killed grandma!' and wants to sue me?"

WOW! I feel for you but in this case, with her psych hx, wouldn't you have implied consent if you didn't have actual consent from a NOK or POA?

[lpnflorida]

I was a student. My patient was a double amputee. He was sitting the wheelchair when in my own self important wisdom thought. hmmmmm I see no need to the leg rests , he doesn't have legs. So brilliantly I take them off. No problem.

I decide I will take him out of his room to see a change of scenery. All well so far.

Then I let go of the handles of the wheelchair and you guessed it the chair starts to tip back wards. Fortunately for us both I caught the chair and beyond our both being startled no one was hurt..

so much for knowing better than anyone,, yikes

[Ruby Vee, BSN]

when changing tubings, i flushed out a central line that had previously had sodium nitroprusside infusing -- oops! how low can a blood pressure go?!

when changing tubings, i accidently switched the heparin drip and the lidocaine drip. patient kept having runs of pvcs, so we'd turn up the "lidocaine" drip . . . until the urine turned a bit pink. six hours later, the next shift caught the error. i almost killed a sweet old man by switching the two drips.

a co-worker of mine pushed 1 mg. of epinephrine instead of the 0.1 mg. that was ordered. immediately, the blood pressure was 260/systolic, the heart rate was 180 and the chest tube cannister was suddenly full. when the surgeon asked my friend how much epi she'd pushed, she said "what you ordered," either unable or unwilling to admit what she'd done. (everyone makes mistakes. the difference between a good nurse and a bad nurse is that the good nurse admits it and sets about to rectify the problem.)

a friend of mine was removing a swan-ganz catheter, but found that it wouldn't pull back easily. so she did what she was supposed to do -- she called the surgeon. the surgeon yanked the swan out -- and immediately the chest tube cannisters were full to overflowing and the blood we pulled out of the art line was pink. autopsy showed that the valve came with the swan.

my first precepter was showing me how to hang blood. it was the second unit, so she pulled the spike out of the first unit while it was still hanging -- and gave herself a blood bath!

feeding tube had been working fine all day -- until i needed to give the patient some cherry red liquid tylenol. (back in the days of white uniforms.) i had a tylenol shower!

i have many, many more but i'd love to read yours!

[Penelope_Pitstop, BSN, RN]

i have many, many more but i'd love to read yours!

aww, come on, ruby...i shared mine! tell us some more!!!

*~jess~*

[Ruby Vee, BSN]

ok, here's a couple more:

back in the days when we put heparin in flush bags, i went to mix one up. the concentration in those days was 1000 units of heparin in 500cc of ns. not only did i accidently draw up 10,000 units of heparin, the nurse i checked it with didn't catch my error. so instead of having 2 units of heparin per cc, the flush had 20 units. flush bags hang until they run dry (or 96 hours have passed), and in that time the platelets got awfully low. i caught my own error when i went to replace the bag and found the heparin vial i'd used, correctly dated, timed and initialed -- but the wrong concentration of heparin! i wrote myself up and threw myself on the mercy of my manager!

i learned never to leave an unsupervised resident in your patient's room. years ago, i was working in a cardiac surgery icu at a university teaching hospital. i had two patients in a double room, one of them ready to transfer out and the other a fresh post-op. we were short staffed that day, and when the time came to transfer my stable patient, there was no one available to watch my fresh post-op. because there were two computers at the mini substation in that room and i was only using one, charlie, one of the residents was parked back there looking at lab results, x-ray images, etc. when charlie volunteered to watch my patient for the few minutes it would take to wheel the other patient out to the floor, i reluctantly accepted.

"don't worry," he said. "i know acls and i can call a code. i can even run a code."

i transferred the patient just as quickly as i could, and ran back to the room to find charlie and a medical student standing over the bed of my fresh post-op. i don't remember which i noticed first: that they were suctioning bloody yuck out of the patient's chest tubes or that there was bloody yuck dripping from the ceiling and splatting on the clean, white sheet covering my patient from the thighs down.

it seems that charlie and the medical student had neglected to put a suction cannister on the chest tube suction tubing (tubing going directly from the wall suction to the pleurevac) before suctioning out the chest tubes. the stuff they were suctioning out went directly into the wall suction and got sucked up into the ceiling. the room was closed for weeks while bio-engineering and maintenence cleaned up the mess and got the suction functional again. and i never ever left an upsupervised doctor with a patient again.

of course the occaisional doctor has managed to sneak into my patient's room while my back was turned.

[BroadwayRN, ASN, RN]

About a year ago I got pulled to the NBN. I took a baby out to nurse about 0200. While that baby was out nursing another new mother called for her baby. I could "not" find her baby. I was in a panic! I soon realized the baby I had taken out to nurse was her baby and not the baby of the woman who was nursing the baby. I had to go get the baby, turn on the lights to show her it wasn't her baby. Then I had to tell the mother of the baby that the baby had been nursed by another woman. I had to call the pediatrician and I had to fill out an SOE. I felt totally stupid, embarrassed and incompetent. I haven't been pulled to the NBN since. :chair: