Mistakes we have made

Nurses Safety

Published

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

Specializes in ER, Med/Surg.

I recently had an instance occur and would like to get your thoughts.

Patient came in to outpatient infusion clinic managed by one nurse. Pt's drug obtained, from pharmacy, infusion started. Nurse 1 needs to talk to a doctor in a different part of the hospital, Nurse 1 leaves patient in infusion room (different than the infusion OFFICE which is across the hallway from the infusion room). Tells secretary that patient has a call bell and that she should check on the patient if she hears the bell. Goes and finds doctor, total time gone about 25 minutes,comes back to infusion clinic. Finds Nurse 2 in the infusion room "fixing" the pump because Nurse 1 forgot to open the roller clamp on the DRUG bag and had only been infusing from the 50mL bag of saline which had all infused, causing the pump to alarm and get the attention of Nurse 2 who was working in a different department.

Patient - No idea anything had happened, completely happy with Nurse 1, even brags to another infusion nurse the next day how well Nurse 1 did. She had been leary because Nurse 1 hadn't worked in the infusion clinic very long. But NOW she was happy with the care Nurse 1 had given.

Nurse 2 - Emailed DON about incident.

Nurse 1 - Fired and told it was bordering on "patient abandonment".

What say you?

Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
i recently had an instance occur and would like to get your thoughts.

patient came in to outpatient infusion clinic managed by one nurse. pt's drug obtained, from pharmacy, infusion started. nurse 1 needs to talk to a doctor in a different part of the hospital, nurse 1 leaves patient in infusion room (different than the infusion office which is across the hallway from the infusion room). tells secretary that patient has a call bell and that she should check on the patient if she hears the bell. goes and finds doctor, total time gone about 25 minutes,comes back to infusion clinic. finds nurse 2 in the infusion room "fixing" the pump because nurse 1 forgot to open the roller clamp on the drug bag and had only been infusing from the 50ml bag of saline which had all infused, causing the pump to alarm and get the attention of nurse 2 who was working in a different department.

patient - no idea anything had happened, completely happy with nurse 1, even brags to another infusion nurse the next day how well nurse 1 did. she had been leary because nurse 1 hadn't worked in the infusion clinic very long. but now she was happy with the care nurse 1 had given.

nurse 2 - emailed don about incident.

nurse 1 - fired and told it was bordering on "patient abandonment".

what say you?

i don't understand why she couldn't have paged the doctor. i think it more than "borders" on patient abandonement. that secretary was in no position to be able to assess if there was a problem, and if there had been, how fast could nurse 1 have made it back to the patient?

unfortunately, i see it happen all the time -- nurse makes a mistake that harms or nearly harms the patient, second nurse comes to the rescue and patient goes on and on about how wonderful the first nurse is -- because she does a lot of chit chatting and pillow fluffing -- and complains at how surly the second nurse was when she came in to "help my nurse." (um, sorry. too busy trying to fix your nurse's mistake that had 5000 units of heparin infusing per hour and is making your urine that pretty cherry color while trying not to counsel her in front of you, the patient and at the same time trying to keep an eye on my demented patient who is right now twirling his catheter tubing like a lasso and exposing himself to all and sundry.)

Specializes in Oncology, Medical.

I am honestly regretting a decision - or rather, a lack of one - from today.

One of my patients is a very sick woman and has been on our unit for nearly a year now. During that year, I've worked with her on and off. Lately, though, her condition has worsened - infections, edema, etc. - and today was my first time working with her in about a month or so.

In the morning, I took her vitals - nothing unusual except that she had a bit of a fever. I told her I'd add some Tylenol to her AM pills - I knew that because of her recent infections, she'd had antibiotics and would occasionally spike a temp but later would be ok.

So, due to my day being a Shift from Hell, I forgot to add Tylenol to her AM pills, so naturally, when I retook her vitals around lunchtime, her temp was about the same. I made sure to add Tylenol to her lunchtime pills.

Fast forward until after dinner. I retake her vitals and her temp spikes even higher to 39.9 degrees Celsius! In the many times I've taken care of her, I've never seen her temp go that high. I call the doctor on call and receive a bunch of new orders.

I am kicking myself now for not notifying the doctor earlier. I think in the back of my head, I was thinking that she had been spiking temps every now and then recently but when I looked through her chart, the past couple of days she's been afebrile. It was just my memory playing tricks on me, perhaps - the last time I had her, she was on antibiotics and was spiking temps every now and then, too.

I'm now worrying and worrying. But honestly, it was a Shift from Hell - four patients, all total care (and we have no aides on the floor - I did everything from baths, to transfers, to feeding), three of them total feeds, stat orders on two of my patients, lots of emotional support for three families, and of course my very sick woman who also had a large dressing and TPN to manage. I was running all day, barely made it to my morning break (I sat down for 10 minutes to wolf down my muffin) and totally skipped my lunch break. And not much help from my fellow nurses because we were short *sigh* Oh the mistakes you make when you're rushed....

I totally empathize. It's a terrible feeling to know you're too rushed to really safely care for the assignment, let alone take care of yourself. I quit my job and started grad school b/c I got too burned out with being short all the time.

Specializes in ICU.

I think it is great to learn from yours and other mistakes. One time I was giving medication to a pt and I got distracted by a pt running their wheelchair into the back of me and I turned two pages in my MAR to the next pt and continued withdrawing medication! It was not until I gave the medication that I realized I had given the pt the other pt's medications. Fortunately they where on the same medication just different times!

Specializes in 3 years MS/Tele, 10 years total ICU, 5 travel.

Oh, the mistakes...

#1: A few weeks into my first job, I forgot to flush a PEG tube. It clotted. Thankfully, my preceptor was able to unclot it with some cola - but the patient and I were both in tears before that point.

#2. A month or two out of orientation, I accidentally gave Lopressor IV instead of PO to my ER admit. No harm done, but I nearly had a heart attack when I realized what I'd done.

#3. About 6-7 months in, got floated to a cardiac floor. Had 2 patients with the same last name, and their first names were... Mike and Mark, or something like that. Anyway, accidentally told 'Mike' that he was NPO after midnight for his kidney scan in the morning. Patient was confused about that, I went back and checked paperwork, apologized a hundred times to him and his wife (who he'd called because we'd mixed up his tests). Nothing had actually been mixed up in the orders, but I had mixed it up in my mind.

#4. Not really a mistake, but... Got a patient on my first day back from vacation. Patient was diabetic, and they'd had trouble with his BS being sky-high for the last 3 days. Docs had tried adjusting his insulins all over the place. In fact, when I go in to assess my patient, there's the medical doc in the room going over possible reasons for his blood sugar to be so high. I do my little assessment, check my orders, and when the doc steps out, I quietly tap his arm and ask if we could make one little change. And take the patient OFF of D5NS at 125 cc/hr. Doc looked horrified, changed him to NS, and in the AM? BS was 120's.

#5. I have a friend that works ER, and he told me this one. He was asked to watch over a new grad/hire while the preceptor stepped away for just a few minutes. He turns around, and this kid's on his way to the pharmacy. When asked, the new kid says he had to go get a pain med order filled, because they don't have it in their pyxis. Naturally suspicious, my friend asks to see this pain medication order that ER doesn't have. Ready...? The kid is trying to go get 1 GRAM of morphine.

When I was in my last week of peds preceptorship in my last semester of nursing school, I had two babies w/ bronchiolitis. Well, turns out I gave PO flagyl to the wrong baby. I realized my mistake right away, notified my preceptor and the doctor (who told the family). I had to have a meeting with the director of the nursing program where we discussed the five rights and three checks and I expressed my complete dismay at what I had done. The director said, "Well, I bet you'll never make that mistake again, will you?" Thankfully they did not kick me out of the nursing program. As a result of this situation, I am completely anal about med administration and the five rights/three checks. The preceptorship taught me a lot about that type of thing but also taught me I NEVER want to work with babies or children or their families again. Give me a heart failure pt w/ an MI and ESRD on HD any day.

I recently started at a new hospital and have only been there for six months. This hospital for some reason still allows MD's to write orders in the chart although they have a system to put in orders electronically. Note that some of the MD's put their orders in but others refuse. I personally think this should be mandatory. The hospital I came from was very strict about MD's putting in there own orders electronically no exceptions even telephone orders were not excepted. I thought this was a good practice since it cuts down on errors due to not being able to read the order from the doc (which I can never decipher their handwriting), also sometimes we do not get the time to check charts for a couple of hours, another is sometimes when receiveing telephone orders cell phones have a tendency to cut out and we miss important information. Oh and not to mention in some cases MD's decide to write the order wherever there is a free space in the chart which is sometimes not even anywhere close to the date. Recently a order was placed in a chart for the pharmacy and faxed by the secretary. The pharmacy missed half the order. Unfortunaltly I missed the order and so did the night nurse so the drug was not given. Needless to say the order was confusing they way it was written. I am receiving most of the blame and the pharmacy refuses to take responsibilty. I have however taken responsibitly for the error and to say the least devasted. I am a very safe nurse and never miss orders and triple check my medications. I have been going over this in my head for several days. Anyone have any ideas for this not to happen again. Thanks ahead for your feedback.

This was not my mistake but it just goes to show never fully trust a brand new doctor.......

While working as a nursing student in the UK, I had a patient who developed an UTI. When asked if she was allergic to any medications, she said "there was this one antibiotic but I cannot remember the name". The patient then tried to call her daughter to find out. Meanwhile, I was working with a new resident who wrote up an order for Tetracycline. I decided to wait untill the patient had found out which antibiotic was bad for her before I gave it (My instructor agreed with me). The resident was yelling at me to give the med and I stood my gorund saying not untill I have a complete allergy list. Turned out patient was HIGHLY allergic to tetracycline, as in they believed the reaction was anaphylaxis. I told the resident and was shocked when he said "Oh just give it anyway and see what happens". Needless to say I did not give it and reported him to my supervisor.

I gave a anti-platelet medication to a patient who was thinking of surgically removing her gallbladder, but it was not a done deal yet. After I passed her AM meds, the surgeon talked to her and she signed the consent. She needed platelets during surgery, and she was placed in the ICU, because she had a heart condition. At least she could be watched closely over there. I now know to hold ASA, Plavix, Coumadin and other "blood thinners" even if the patient has not given the go ahead for surgery. Yep, I will definitely be careful.

Specializes in ER, progressive care.

I went into the wrong room and introduced myself as the patient's nurse for the night and did a full assessment and flushed their IV...then when I walked out I realized I was in the wrong room! No wonder why were confused because shortly before their REAL nurse for the night came in and did everything I just did!

I almost gave the wrong dose of insulin to a patient. CNA told me a blood sugar was 300-something, but REALLY the blood sugar was like 203. She got the results mixed up with another patient. The results are always uploaded into our system from the glucometer once it is "docked" at it's station...so now I know to always recheck the result if I'm not taking the blood sugar myself!

We had a patient come up from the ER who needed 2 units of blood. 1 unit was already infusing but the ER ran it very slow and it nearly went past the 4-hour mark...oh, and the nurse didn't do any of the hourly vital signs! The patient was okay, thank goodness. I hung the 2nd unit and had it going and then the clerk asked where the consent form was, and I said, "what consent form?" and then I nearly flipped! It was signed in the ER but we didn't have a copy of it. And here I have blood infusing on this patient. ER lost it, but we still needed that consent form in the chart. I got another form signed and explained that it got lost along the way (because it really did) and there were no problems. Now I know to always check the chart for a signed consent form!

I was pulling out a Norco for a patient. Well I wasn't paying attention and thought I was only supposed to pull out 1 tab, but really I was supposed to pull out 2. I rechecked the order on the MAR after pulling out just one and realized I needed to pull out another one! So I just tried to return it but instead of having me return it to it's respected cubicle, the Pyxis had me return it to "box 39" (the one that can only be opened with a key). Then the Norco was grayed out because it was out of stock...so I got my correct dose from the Pyxis down the hall.

The next morning my manager calls me telling me there was a "discrepancy" and that I needed to explain what happened. I came in and wrote up my discrepancy report for the pharmacy. She joked and said, "you didn't look high this morning and your pupils weren't pinpoints so I believe you" and I just laughed. I told them I would submit to a drug test right then and there if pharmacy didn't believe me!

This one happened recently...Patient was post cardiac-cath, had a femoral sheath that needed to be pulled...but 2 vital pieces of information were missing from the report I received from the off-going nurse: 1) the sheath was to be pulled as soon as the patient came to the floor and 2) the patient received no anticoagulation. And cath lab made it confusing by hooking up a bag of heparin to the sheath, even though it wasn't infusing. The nurse said to just pull it when I can...well, I had an admission right at shift change. So I couldn't get to it until around 20:30...I called the cardiologist asking if it was okay, and he said it was (because there was no order of WHEN to pull, even though the cardiologist argued that there was an order...) and then minutes later cath lab call saying the sheath should have been pulled earlier than now, the artery could have clotted off, blah blah blah...I was expecting to get an EARFUL by the cardiologist but he just told me it should have been pulled earlier and him and 2 cath lab techs came up to pull it...no problems. Of course it still falls on me, but I definitely learned after that experience!!! I'm just glad there was no harm done to the patient.

Specializes in ICU.
As a student I crushed a K-Dur (potassium) tablet and put it down an NG tube. I didn't realize the K-Dur wouldn't dissolve and it ended up clogging the tube :eek: Oh, and this happened in the middle of the night. I dreaded having to call the Dr. in the middle of the night for a new order to re-insert the NG and have to admit my stupid mistake but fortunately (for me) the pt. ended up pulling the tube out shortly afterwards and then I had a legitimate reason to call.

Another time a nurse told me to give pt. xxxxxx a "20mg Bentyl injection." Well I didn't bother to check the order myself and I ended up giving it IV instead of IM. Bentyl is not indicated for IV use...it can cause a thrombosis and/or embolism when given IV. Had to write that one up and kick myself later.

I always remind myself that 1) always follow the five rights, 2) you can never get vital signs too often, 3) when in doubt, stop and find out first and 4) know your institution's policies!

You called a doctor for an order to reinsert an NG tube? Do you call a doctor every time an IV goes bad for an order to put another one in?

+ Add a Comment