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

[LilpoRN]

I had a very smart, experienced RN tell me a story about a patient needing an esmolol drip back in the days when the nurses had to mix it up. The nurse who mixed it wasn't experienced and had a senior nurse check it for her. SOunds like the situation was chaotic and the new nurse explained her calculations to the senior RN and both agreed it sounded good. Well, it wasn't! the concentration was way too high and the patient ended up coring. The lesson was never explain your calculations when having another RN check calculations. Just give them the order, the concentration, and whatever else thay need to figure out the math on their own. I thought it was a good point.

[ivorybunny]

what a good topic to start, and you're right, if you don't learn by your own mistakes, you can learn from others who have had them. i work on a cardiac floor and there have been several things i can tell you about...

my first huge mistake was done shortly after i was on my own from orientation. during report, i was told the patient was to receive 2 units prbcs, the secretary had written it on the mar and i was trusting the word of a more experienced nurse. well, go to hang the blood, patient has a temp. got orders to treat that, then the bp was high, so call and get orders for that. as the second unit is almost done, something made me go back and look at the order. the order read type and cross for 2 units of prbcs. there was never a transfusion order. terrified, humilated, and dumbstruck, i had to call the md and explain everything to him. i got quite an earful and now i always check blood orders before giving them.

another one that happened on our floor, patient had a heparin drip running and somehow the pump got set to 99ml/hr instead of 9ml. almost all of the 250ml of heparin had been infused by the time it was caught. now our protocol is that two nurses have to sign off of heparin adjustments.

another incident was the monitor tech was calling a nurse about a rhythm, believe it was bradycardia. and the patient was treated for it. however, the actually monitor box was on the wrong patient, so the wrong patient got treated. another hospital procotcol, we now have to check each patient's tele box number with the monitor tech to assure we are looking at the right person. oh, and treat the patient not the rhythm.

another one told to me was there was an order for furosemide 40mg iv and phenergan 40mg iv was given instead. patient ended up in the nicu unit on a vent.

this has probably happened to more than one of us, but you have a flush bag set up with antibiotics piggybacked in, and when you come back to check, you've been running the flush in instead of the antibiotic.

[Ruby Vee, BSN]

another incident was the monitor tech was calling a nurse about a rhythm, believe it was bradycardia. and the patient was treated for it. however, the actually monitor box was on the wrong patient, so the wrong patient got treated. another hospital procotcol, we now have to check each patient's tele box number with the monitor tech to assure we are looking at the right person. oh, and treat the patient not the rhythm.

decades ago and far, far away, i worked at an institution that had just built a big, beautiful new hospital. i was there the day we moved in to the new ccu. patient in room 2 is lying in bed sleeping peacefully when the whole code team arrives, slapped on the paddles and shocked him. still vt, but the patient is awake and pretty peeved. so they sedate him and shock him again. still vt, and his art line pressure is dropping rapidly. by this time, he's sedated and not all that responsive. so as they're getting ready to shock him a third time, someone calls out "wait! i've got a pulse!" pulse is 70 (not at all correlating with the rhythm on the monitor) and blood pressure is 110/60. a little low, but ok.

meanwhile, the patient in room 3 is deader than a doornail and a lovely shade of blue. turns out that the wiring was screwed up . . . signals from room 3 were displayed as having come from room 2 and vice versa. so the patient in vt died and we treated a healthy patient in nsr. moral of the story -- check the pulse first!

i once worked in a hematology unit where we drew labs from hickmans every morning and flushed them with 10cc ns. this was before the days of prefilled saline syringes, so pharmacy used to mix up our saline syringes and send them up in a bag of 10. (they did the same with the kcl that we added to our iv bags. perhaps you see where this is going.) drew my labs one morning, flushed the hickman with my 10cc "saline" flush and the patient starts screaming that "it burns!" and promptly arrested. afterward, it was determined that i'd flushed the hickman with 20 meq of kcl drawn up and labeled by pharmacy as flush solution. that was bad enough, but it happened three more times that same week to other nurses, once to the same patient, who knew what was happening and survived a second code.

moral of that story: if you know there may be a problem with some of your "flush" syringes drawn up by pharmacy, send them back to pharmacy and draw up and label your own! i'm sure there are other morals to that story, too, but that's the one that grabs me right now.

[Not_A_Hat_Person, RN]

I haven't found my first RN job yet, but I've already made some mistakes.

I volunteer in an ED. Occasionally, I move patients. One busy day, the triage nurse asked me to move a patient from from room 1 to room 7, and bring the chart. I walked into room 1, introduced myself, and said I was moving her to room 7. I couldn't find her chart, so I went back to talk to the nurse. She said the patient in 1 needed a wheelchair and the chart. I said "The patient's on a stretcher." She insisted I move the patient. So I did.

The ED had 3 triage rooms and about 50 treatment rooms. I moved the patient in treatment room 1. She wanted me to move the patient from triage room 1. Since then, I always make sure I have the name of the person I'm supposed to pick up.

I once did a fingerstick blood sugar without wearing gloves.

I once changed a baby's diaper without wearing gloves.

One of my complex med-surg patients was gasping for air, with RR of 32 and a sat of 92. I told the nurse she was gasping for air and her respirations were 32. She responded "Yeah, she's been running that." I couldn't find my instructor, so I charted it. The doctor was very concerned, and they ended up calling an "almost code" and transferring her to the ICU.

The nurse said "You need to tell someone about stuff like that." I replied "I told you about her respirations." I was already on clinical probation, and I got written up. I explained my side in writing. After that, I told the nurses about anything the least bit abnormal. They were annoyed, but I passed clinical.

Another day, I heard during report that my patient was discontinuing an infusion after the last 100 cc. When the pump went off, I checked it, paused it, and asked the nurse if I should disconnect it. She said yes. With my instructor next to me, I disconnected it. I did something wrong, because the next thing she said was "You just contaminated the tubing." It turned out that the patient was supposed to get another 100cc. They ended up using a new bag and tubing.

I did a rotation at a rehab hospital, on a floor with 40 patients, a lot of diabetics, a lot of people on corticosteroids, and 3 glucometers. The MAR had 3 sheets, including 1 for diabetics.

My patient was at lunch, but he needed a FBS before he ate. I grabbed his diabetes sheet, intercepted a glucometer, and took him to a corner, trying to be polite (everyone else thought it was a good idea). The glucometer shut down, and I had to track the nurse down to set it back up. By the time that was done, lunch was over, and my patient was back in his room. My instructor told me to grab his MAR, so I did. I matched the patient numbers on the diabeters sheet with his bracelet, got the FBS, and administered insulin.

When I opened the MAR to put the diabetes sheet back, the sheet was already there. I had the wrong MAR. Fortunately, I had the right diabetes sheet, but it was very scary. The hospital had 3 different sliding scales; If I'd used the one in the MAR, instead of the one in my pocket, I would have given him 15 units instead of 5. That incident reminded me to always follow the 5 Rights, not matter how busy you are.

[sharpeimom]

I was a fairly new nurse and my soon-to-be discharged psych patient was going home to spend the day with his family just as I was coming back from lunch. I had made up his meds and put them in the plastic containers we used just for day pass pts., and gave them to his wife for later and off they went. They'd been gone about half the time when the phone rang and it was my patient. He had a "quick question..." He had just taken his meds and wanted to know whether those meds would "be safe with the other pills that other nurse gave me before I left the hospital?":eek: Huh? Turns out, I had forgotten to sign my meds out so the other nurse thought she'd help me by giving them for me just a bit early. All I can say is that I'm grateful he forgot about them and ended up taking the second batch nearly four hours late. We were both reprimanded but not written up. The good news is that it made me compulsive about meds giving.:)

sharpeimom:paw::paw:

[TiredMD]

One of my complex med-surg patients was gasping for air, with RR of 32 and a sat of 92. I told the nurse she was gasping for air and her respirations were 32. She responded "Yeah, she's been running that." I couldn't find my instructor, so I charted it. The doctor was very concerned, and they ended up calling an "almost code" and transferring her to the ICU.

The nurse said "You need to tell someone about stuff like that." I replied "I told you about her respirations." I was already on clinical probation, and I got written up. I explained my side in writing. After that, I told the nurses about anything the least bit abnormal. They were annoyed, but I passed clinical.

I am continuously amazed at how nursing students are treated in school.

As medical students, we are routinely abused, harassed, and publicly humiliated. This is normal and expected.

But when medical students make clinical errors (failing to report an important finding, screwing up an order, missing something on a physcial exam), they are not formally punished, because this is expected. Students screw up, that's why they're students. You can and should berate them for it, yell, given them extra work, whatever. But you don't sanction them formally or kick them out, because making mistakes is a normal part of learning.

I am just blown away that a nursing student could be put on probation or written up because they didn't make a big enough deal about a patient's vitals or breathing pattern. Yes, it is important that this finding be caught and addressed, but it is the responsibility of the person with the license, not the student who is still learning what matters and what doesn't. When a clinical finding is missed, the preceptor should be held responsible, not the student.

It is a shame that y'all are subjected to that kind of learning environment.

[sissiesmama, ASN, RN]

Oh, lilpo - I read your post and just had to throw in my .02. I figured that had never happened to anyone but me. I was working on an ICU unit at a LTAC unit, and the MD came in to put a CVL while I was at lunch. The charge nurse assisted and the MD wrote an order, "OK to use CVL for TPN and Lipids." I was looking back after the patient was done and didn't see xray results. It had not been done, so I ordered it. The radiologist called immediately after he saw the film and said "Do not use it. Do not touch it. Call the idiot who placed it and tell him he put the line into the carotid!!" He was so freaked! He wasn't a happy camper when I told him the MD had already started all his IVs before he left the unit.

I called the MD that placed it and told him about the radiologist's call, and he just said, "Oh, it's OK, you can pull it. Just put a bandaid on it". A freaking bandaid on a carotid artery??! No thank you!!!

[Thornbird]

I was working in a LTC and had a note saying Flu vaccine was in and to try to get as many as possible done. I gave 20 and completed all the documentation. Then discovered that the vaccine I gave was from the previous year that nobody threw out when it expired. I had 20 med error reports to do plus the embarrassment of notifying the MD's and families of the error. I'm compulsive about checking expiration dates and disposing of expired meds now!

[sharpeimom]

I'm compulsive about checking expiration dates and disposing of expired meds now!

Funny how it only takes one time... In the goof I wrote about, I was new to psych and had only been out of school about 6 months and was soooo careful (or so I thought) about everything I did but allowed myself to be distracted by another nurse talking to me and forgot to sign off on the meds I'd just pulled. She was an older no-nonsense woman who treated everyone under 40 or so like kid and I allowed myself to be intimidated by her.

sharpeimom:paw::paw:

[DeadHeadRN, BSN, RN]

We had a brand new nurse come to us and tell us that she had to go down to pharmacy to get morphine. We are a surgical floor so usually have plenty in the narc cabinet. We asked her if she'd looked in the cabinet and her response was "yes, but there's only morphine sulfate in there, the order is for morphine." WOW!!! She was fired several days later for giving dilaudid instead of morphine.

[Susan9608]

It's kind of nice to read about other people's errors and realize you aren't the only one who's done something careless or just plain stupid from time to time. :)

I took care of a congenital heart patient once who pretty much chronically received blood transfusions. He got one about every 2-3 days. I took care of him one day, and his mother said to me, "When is he going to get his blood today?" I was a little puzzled, because I knew he had just gotten blood the night before, but I went and checked my orders and sure enough, there was a blood order, with that day's date on it, timed for 1200. It was around 1600 or so, so I felt like it was actually late. I ordered the blood, got it, checked with another nurse, and gave it. The next day I came in and got my butt chewed by the night shift doctor because apparently the blood I gave was the order she had written the night before and that was given the night before. Instead of using military time, like she was supposed to and writing 0000 or 2400, she wrote 1200 and didn't specify AM or PM. And then the night nurse who gave it didn't sign it off. And the blood blank didn't notice that it was the exact same order that had been sent to them the night before.

I told the night shift doctor that if it was anyone's fault it was hers, because she should have used military time ... and that this proved why hospitals use military time to begin with. And, compounding her error was the fact that the night nurse didn't sign off the order, signaling that it was complete. But the doctor kept insisting that *I* was to blame because I should have recognized her signature on the order and realized that she was the doctor on nights that week and not the one on day shift. Whatever. Luckily, my manager didn't see it that way.

It shows you how important it is to sign off your orders after you complete them, though.

[ybstressed, LVN]

We had a brand new nurse come to us and tell us that she had to go down to pharmacy to get morphine. We are a surgical floor so usually have plenty in the narc cabinet. We asked her if she'd looked in the cabinet and her response was "yes, but there's only morphine sulfate in there, the order is for morphine." WOW!!!

:omy: Thats scary! I would like to know where she works now.