Mistakes we have made - page 6

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... Read More

  1. by   ninja-nurse
    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.
  2. by   rntj
    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.
  3. by   Lmyers0010
    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.
  4. by   RnfromUK
    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.
  5. by   whichone'spink
    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.
  6. by   turnforthenurse
    [FONT=Hiragino Kaku Gothic ProN]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.
    Last edit by turnforthenurse on Apr 23, '12 : Reason: typo
  7. by   FCMike11
    Quote from ERnurse2001
    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 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?
  8. by   FCMike11
    Quote from Daliadreamer
    Great thread--

    My first ever med error was when I was working in LTC. We had handwritten MARS (AWFUL- you think MD handwriting is bad?). My patient was getting po lasix, which I only noticed she was getting once a day. I worked the day shift. It was halfway through the month, and I realized that I had missed her 1400 dose every day that I had worked. I only realized it after I saw another nurse's signature by that particular time, on my days off. To my defense though, the 1400 was handwritten and squished under the 0900 line and could barely be seen. The nurse that had handwritten this particular MAR was the nurse that had worked on my days off and knew her own handwriting.

    I transcribed a medication wrong from the hospital orders to the LTC MAR

    When I was brand new to a hospital setting, I had never wasted anything before, had never seen it done. I guess on my orientation I never had to waste anything. I went home with 1mg dilaudid in my pocket. The next day one of my patients was in pain and the pyxis was occupied, so I just used the extra dilaudid from the day before. WOW, I know. I cried for several days. Luckily my co-workers were really supportive.

    I've run antibiotics at a slower rate than prescribed

    I have given IV bendryl 25mg instead of 6.25

    I've probably done other errors without realizing, like most of us have
    You didnt really cry for days right?....
  9. by   Gold_SJ
    Quote from FCMike11
    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?
    In many facilities it is policy to ring the doctor for a new insertion of a NG tube. Is in my facility. It's not for a new IV insertion but the private hospital next door to our Public one it is policy to ring and ask. Depends on the hospital.

    You didnt really cry for days right?....
    And that comment has no basis to the discussion. How people deal emotionally with a mistake is completely varied. This thread is to have fun and share, to learn from one another not to pick apart how one responded. In my opinion anyway.

    XD Anyway sharing mistakes...hm when I was in my postgrad working on our Medical/surgical floor, I have no idea why, but I completely missed a woman's insulin. I realised four hours later when going to give her lunch insulin. I just stared at it then horrifyingly had to go tell the Co-ordinator and Dr. The resident was 'Why? Whyyy?' He was as stressed as I was, I could only tell him I have no idea, I've never missed a drug before, I gave her everything else. So he had to ring the surgeon to tell him. She was fine but I'd put the poor resident in hot water. Could only apologise and then self report on our Prime system. Bleh was far more anal over medications from then on.
    Last edit by Gold_SJ on May 20, '12
  10. by   Lynx25
    First day in LTC- first day as a nurse.

    I pulled out my meds with my preceptor (Right meds! Right Dose!) Double checked everything extra closely (Right time!)... first day ya know- I haven't figured out that I need roller skates to get everything done in time with 30 people. Now, we don't use bracelets or any ID here- because it is a "home", so I asked someone to "Point out Ms XXX, please, I'm new!". The aide happily pointed to one of 15 or so LOLs sitting up at the dining room, and I fed her the pills... (Right route! I'm awesome!)

    My preceptor came around the corner, and asked how it went, and pointed... to someone else. (OH GOD WRONG PATIENT!!) Turns out it was the LOL sitting beside the one that was pointed out to me, they were both in matching gerichairs, both tiny with white hair, and both snuggled up in matching blankets.

    So... I got to fill out my first incident report. Nice. No harm done.

    Absolutely a learning experience.
  11. by   dirtyhippiegirl
    I missed an abnormal EKG on a new admit. He had a change in LOC which caused another EKG which was the same but still abnormal. We ended up doing cardiac markers, etc. His heart issues were old, old, old. But I was still written up -- rightly so, I could have ******' killed someone.
  12. by   tn nurse
    Well, on to making errors with medications. Has anyone here lost their job of being a nurse, well, I am fairly new nurse, grad in august 2011. I made 2 errors over the past months and now I can lose my job. I love my job and am careful, I made a mistake and now if I have any other med errors I am fired! Thats it, don't they realize this is a nursing job and I am being careful, I felt worse than my employer knows and I still am worried that I could lose my job I love.

    What to do? Be perfect at everything or just keep beating myself up over this?
  13. by   Morainey
    My latest bonehead mistake was not putting in an admission order (in addition to the diet, activity, meds, etc on an ER admit). Sometimes admitting or the physician enters that particular order, so I go out of the habit of checking it. Sigh. You can bet I'll always check it now!