Nursing errors I learned from...

Nurses General Nursing

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OK, to offset the thread "What was the most incompetent thing you ever saw a coworker do" I will start this thread. How many out there are brave enough to admit to mistakes they have made, and what we learned from those mistakes?

Let's make this thread a positive one and hopefully we will help each other avoid the same errors in the future....:)

Here's one of many of mine...I will add more as we go:

I got hoodwinked into staying over and doing a double. I was exhausted with a sick baby at home and had not slept well in a week. I was like a zombie making that last med pass at 6 am..and I had 13 patients on medsurg to pass meds to.

Well, we were short (and this was 20 years ago...not much different now is there?) and I was behind so I cut corners...found out later I had completely mixed up two patients' medications.: patient A got patient B's meds and vice versa.

Well, luckily these ladies were astute enough to not take them. I wish they had said something to me at the time, but as I said, I was rushed and behind so I probably didn't give them a chance...just pushed the pills at them and ran off....

My director called me at home later very sternly..to come in for a counseling. I felt awful. The ladies, of course, had spoken directly to my boss about this mistake I had made. No harm done, Thank God, as the patients didn't take those incorrect meds I gave them.

I learned not to let myself get talked into working extra when I know I'm already exhausted. Saying 'No' is the safest thing to do in those circumstances, to avoid potentially serious errors due to exhaustion.. And I also learned never to shortcut the '5 Rights' of medication administration because I am 'running behind.'

Anyone else ready to 'fess up'? :imbar

RNinIcu...your post made me laugh! I never shave a patient with an ETT in without wrapping a washcloth around the base of the tube....for the same reason you said....I accidentally cut the line to the balloon once too!

Luckily the respiratory therapist came to my rescue with a 'repair kit', and saved the day. :)

But I always got ribbed by that therapist then on...he said he always carried a repair kit on him when I was on duty...LOL!:roll

The first time I made an error it involved giving patient A's meds to patient B. I realized my mistake after the fact, and reported it to both the MD, and nursing supervisor. Had to stay over and fill out the incident report - and patient B had to be monitored for any adverse reaction, which fortunately, there were none. I made this error while working my sixth night in a row between two different facilities. Lessons learned: always check the five rights, never work so many shifts in a row again. I'm convinced this mistake was mainly a result of how exhausted I was.

Mattmom81 is so right on about staying alert and not trusting that things have always been done properly before you start. Pharmacy has been known to mislabel medications (for example, I've found lasix in a bag assigned to a patient receiving pepcid - she didn't even have an order for lasix . And recently a patient had someone from the lab come draw his blood without any orders - turned out there was an order for his room mate to be drawn, but he had been discharged the previous day. This wouldn't have happened if the phlebotomist had checked the patient's wrist band.

I just thought of an error I made about six weeks ago. A patient was admitted from ER with some kind of cardiac problem. I got report from the ER nurse. The patient came up, I assessed him a filled out the paperwork. It was right before the shift change, so I was trying to get out in a hurry. Evidently, the ER was bolusing this man some IV fluids and I never checked the rate of the IV pump against the admission orders. I don't remember ER telling me that he was being bolused (but they might have, I just don't remember). Any way, the nurse who followed me didn't check the rate, and she infused a liter of fluid in an hour or so. The man got into some CHF problems, which he had a history. It improved with Lasix, and I don't think he was seriously harmed. But, I check those pump rates now! :cool:

That's a good point, Deespoohbear...your story made me think about the fact that ER has their own med stocks and many times will 'mix their own' IV meds, and/or use a different concentration. They may have different protocols than the units do for these drug mixtures.

It's important to look at the label to see how it's been mixed ie Heparin or Nitroglycerin...it can get confusing. I have caught myself titrating a chest pain patient on a Nitro drip only to realize later I didn't have a 50/250 mix but a 100/250 mix and I was therefore charting the incorrect mcg...we live and learn.

Same with Heparin....I have had trouble reaching the desired parameters for PTT only to finally check the bag and see i was titrating to the wrong mix...ER had mixed a drip with different concentrations!

Sooooo.....always double check ER's (or any other unit for that matter) concentrations in IV mixtures and make sure they are correct for your YOUR policy. And if it's not labeled (I have had this happen frequently...ER gets hectic and they forget to label the bag) DO NOT assume it is the same concentration YOU would hang....check it out. :)

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