Nursing Mistakes

[tama18, BSN]

I am just finishing up my first year as a nurse. I am working in pediatrics on a floor that has trauma rehab and pulmonary kids. I've smacked myself in the face recently over making stupid mistakes. Need to make myself feel less alone by hearing some of yours. Here's mine:

My kid was napping while her water flush was running through her G tube over an hour. Family was there, they are trained and typically take care of the G tube feeds and flushes and meds. Water was ordered as 210 mL at 210 mL/hr. Mom was busy with the patients sibling so I set it up for her. The same pump is used overnight for a feed that runs 90 mL/hr for a total of 610 mL of formula. I changed the rate but forgot to change the dose from 610 to 210. I did not go in to check on my patient after the hour was up because she was napping and the mom did not want it to be interrupted. The pump is set to stop when the dose is complete and mom knows how to do everything. It had been a little over an hour and the mom came out yelling my name and said "YOU DIDNT CHANGE THE DOSE IT WAS SET TO 610". So I went in and checked to see how much the patient got - 320. I put a syringe on her and decompressed her stomach and was able to pull out about 30 mL. Mom was freaking out and yelling about how the stomach was SO distended. The stomach was not distended at all. It was soft and the patient was laughing while I was decompressing saying it tickled. I reported it to the charge nurse right away, apologized to the family and everything was fine. It was just extra water and she just peed a little more. But it just scares me because I keep thinking what if it wasn't just water?

My second one was the next week when I had a vent/trach baby on a Methadone, Valium, Clonidine wean. For some reason I did not give the 1700 Clonidine. I think in my head I had planned to give her all her 1600 and 1700 meds together but I ended up giving her the 1500 and 1600 together and accidentally crossed them all off my list. It was about 2030 when the night nurse called me asking if I gave it. I was confused thinking I had and then realized I had given the 1500 and 1600 together so it screwed me up. They had to call the on call pulmonologist and they decided to just skip the med. Everything was fine. The patient didn't have any withdrawal symptoms. But again I kept thinking what if it was something else I forgot. I've continued to have nightmares about forgetting things and causing horrible outcomes. Luckily my manager asked me about it and then patted me on the back and said "That's okay. It's a good learning experience for you. Are you okay?"

Originally I was upset about being placed on a chronic care floor rather than an acute care or ICU floor for my residency. But now I am kind of relieved because had I made mistakes like these in the ICU or on an acute care floor with something else things could go a lot worse. I am thankful to get my new grad mistakes out of the way on a unit like this. And I've had a nursing student since then and told her about all of it. She was worried about getting a good job when she graduated. I advised her to find a good general unit to dip your toe in before going head first into an ICU or somewhere more acute.

[KarenMS]

Not judging the mistake, because they happen of course. Just curious how the little girl got more than 210 even if you hadn’t changed the dose. Wouldn’t you just have put 210ml in the bag if that was the intended flush?

Edit: never mind, I’m thinking you must just have a large bag that you fill once a day and it pulls from that? At my Peds facility, we use smaller bags that we refill all day with each feed and flush, so that’s where my head was.

[Lbu]

I ran a chemotherapy dose (which can cause severe anaphylaxis) at double the rate ordered on an almost 90 year old

Everything was fine but I cried so hard they sent me home

[Nurse SMS, MSN, RN]

I gave a guy an extra dose of Norco. He had a good nap and I was his favorite nurse during his stay. But it rattled me. This was during my third shift working independently.

I hung an antibiotic but forgot to unclamp it. No patient harm but it rattled me.

I gave an elderly woman Ativan and she took off her gown, got up to wander her room and was found face down on the floor. No patient harm, but it rattled me.

We are human beings taking care of human beings. It is good that you care about your mistakes. These won't be your last. This is how we learn and become "seasoned" and one day someone else, new to nursing maybe or maybe even well experienced, will make a mistake - and you will be in a position to offer them the kind of grace you are needing now. Hang in there. Keep talking to mentors you trust. You are a good nurse.

[AnLe, ASN, RN]

I gave a patient hydralazine 20mg IV push instead of his furosemide 20mg. (I had the hydralazine for a different patient in my pocket.) I did not do my usual routine of labeling bags and storing all patient meds this way. I reported it to my charge, director, and on-call physician; I work nights. Patient's BP did not change. I checked his BP q30 min for 2 hrs per on-call physician. I was so ashamed and was/am paranoid about my med administrations now. I think about it often. Had a talk with my director and received a written warning.

Patient was fine, had no complaints of any kind besides myself keeping him awake. He discharged soon after.