I can't believe that I made such a stupid mistake and am kicking myself!!! - page 4

I had to give a new IV to my patient, but I couldn't get it, so I left. However I forgot to get the tourniquet out from patient's arm, and I found it out 1 hour and 30 minutes later... He was a... Read More

  1. by   feelingdumb
    Once when I was in clinical as a student nurse during my last rotation on the ICU I was in a hurry giving a patient his insulin injection... my preceptor had drawn up the insulin and capped it super tight. When I tried to pull off the cap it was very difficult and when I finally successfully pulled it off it made my hand jerk back. I was in such a hurry trying to get things done that I didnt realize when it had jerked back the needle had barely touched my other gloved hand and poked me just before I injected it into the patient. when I was charting I took off my glove and saw a small poke on my finger. I literally had a panic attack. I told my nurse and asked what we needed to do. We informed the patient and infection control determined that nothing needed to be done after that, since they already had all my blood-work I literally was in a panic all day I felt horrible and so stupid. I cried myself to sleep that night. My nurse was very nice though and she reassured me that it was ok and very brave of me to own up to it because others would just brush it off and be too embarrassed. She said these are the types of mistakes we only make once... Despite her comforts I still feel horrible even though the patient was very understanding about it I feel so dumb. I will never let myself hurry that quickly again.
  2. by   DeeDee_RN
    When I was orienting I forgot to waste once! I pulled from the Pyxis withdrew some morphine and promptly popped the vial in the sharps, I didn't even think about it until the next day. I let my preceptor know and she said not to sweat it but I felt horrible, I ended up reporting it to the director. One "event report" and drug test later I was ok and felt better about the situation. I have made a lot more dumb mistakes and every time it eats me up for a little while, but as pp said, I don't ever do it again!
  3. by   CaitlynRNBSN
    I actually work on a committee that discusses events. The reason for these events is not to "document what happened" its because, there was something wrong with the system to allow this to happen. Why did this happen?? It happened because you forgot. Why did you forget? Because the tourniquet was white and blended with the bed sheets.
    What can be done to prevent this in the future? Well, maybe we can get bright blue tourniquets. Or if your patient gowns are blue, maybe get red tourniquets. People who order this stuff don't work at the bedside, they realize that. Sometimes they don't think of things like that and they rely on us to give them that information. "This tourniquet isn't working because it blends with the bed sheets. Perhaps we could start using colored ones?"

    One time, right after we had purchased new types of lotion/soap/conditioner/shampoo bottles, we had a CNA who lathered up a patient with conditioner in her skin after her shower. she thought it was lotion and meant to lotion the patient. all the bottles looked the EXACT same. You had to look at the small, fine print to see if it was soap, lotion, shampoo or whatever. She came to the desk and was like "Wow. This new lotion is terrible." We figured out what she did, and she felt AWFUL. we had to get the patient back into the shower to wash off the conditioner on her skin. We did fill out an event about it. not to get her into trouble, but to make a point of HELLO!!! this could happen again. Hospital realized how simple it was to make that mistake and we ended up going back to our old soap bottles, lotions etc. Luckily the patient had a sense of humor and laughed about it
  4. by   Heidimc
    I once didnt sign for giving warfarin and a nurse thankfully called me and asked if I gave it, I had and told her so ( if not signed for it not done thing) so glad she did call thus didnt give it or coulda gone so bad, I felt so bad about it even though no harm came but it taught me a lesson, same as last people said I'll never forget that again. Now I put lil boxes next to my handover sheet warfarin/insilin/MST/fluids, and I check it before end of every shift to make sure never forget again. We all make mistakes we're human and nurses just learn and move on
  5. by   fermium
    I once gave amoxicillin to someone with a penicillin allergy. He went into anaphylactic shock. Luckily, a good shot of epi saved the patient's behind (and mine).
    We all make mistakes. The trick is to not repeat it.
  6. by   MARYRN2009
    Its ok dont beat your self, these things happens especially when you are busy. Just dont do it again
  7. by   rondragon
    lesson learned and charged to experience.
    For sure it will never happen again.

    thanks for sharing.
  8. by   Overland1
    This reminds me of a patient I had while doing clinical rotation in the ER as an EMT student. An older guy comes in for chest pain and I had to start the IV and draw blood (the old fashioned way - with a syringe) for the lab. Applied tourniquet (they were latex and light tan and tubular back then., did the insertion and draw per protocol; when reaching for the IV tubing, I did not yet pull the tourniquet, and what seemed like a gallon (OK... a liter ) of blood leaked onto the sheet within just a few seconds.

    Lessons learned:
    1.) Keep all supplies safely closer
    2.) Pull the tourniquet as the last tube is being drawn

    As a student, I was embarrassed until the patient told me he did the same thing back in medical school; he was a retired doc with a great sense of humor.

    More recently, with the push for latex free stuff, our tourniquets are either bright blue or orange.
  9. by   Been there,done that
    I got a call from the IV nurse.. "please go check patient so and -so", she had that little bell going off and thought she made that mistake.

    Yes, the tourniquet was still on the patient 's arm.

    If a 20 year veteran that places IV's all day can do it... you need to
    STOP beating yourself up!
  10. by   Orca
    Quote from RN Chaos
    Anyways, it is always great that there are such many compassionate nurses out there trying to help each other. I wish I could be such a nurse someday!!!
    You already are. Your compassion and your concern came across very clearly in your initial post. Once you discovered your mistake you did everything possible to ensure that your patient was all right. You also owned up to your mistake and reported it properly.

    There isn't a person on this forum who hasn't made a mistake. Learn from it and go on. You have already displayed one of the main attributes of a great nurse. Go forward from this and be one.
  11. by   chrty_knox
    I have really beat myself up over a few mistakes like yours. My new motto is learn and try not to make them again and press on. My recent ridiculous mistake was after a long night shift and my brain was not working and I reported that my pt had a BUN of 133 well that was his glucose not BUN and I was so tired I didnt realize my mistake till after report and clarified his BUN was 22 not a horrifying critical value of 133. I have been thinking about this and how everyone must think I am such an idiot. I have to stop beating myself up and press on. I AM glad I can vent here
  12. by   Mursechico
    What ended up happening if you don't mind sharing?
  13. by   Rose_Queen
    Quote from Mursechico
    What ended up happening if you don't mind sharing?
    This thread was started 3 years ago, and the OP hasn't been on the site in several years either. I doubt you will receive a response from the OP.