Bane 155

A little over 2 years

How many have you made, and how severe were they? I recently accidentally bolused my intubated pt with ~200mcg fent while trying to prime new tubing, because I didn't trace my lines well enough and thought it was disconnected. Immediately told my charge and the care team. We watched her closely and nothing happened, but obviously the situation could have been much worse. This got me thinking about the mistakes I've made over the course of my 2 years as an ER/ICU nurse, and my self-esteem is in the gutter. I was hoping to get some feedback and maybe hear from some of you if you feel open to sharing. Below is every error I've made in my career, in complete honesty, from least to most severe (yes, I do keep a list so I never forget them). Near misses: I almost gave a 4 month old an ordered dose of ibuprofen. This dose was orderd by the MD and approved by pharmacy, and I too failed to catch the contraindication. My charge did before the med was given, because all pediatric meds in that ER require cosign. I almost administered PRN glucagon thinking it was a 1-time scheduled dose. That pt had arrived hypoglycemic but was on a dextrose drip and CBG was 80 at the time this error almost happened Reached the patient, but did not cause harm: I once gave IV thiamine via the IM route. The pt had multiple meds due, some IV and some IM. I was used to giving thiamine via the latter, so my brain short-circuited. Luckily the formulation was approved for either and IM absorbtion is apparently very good as well for that specific med I forgot to halve a mestinon tablet I ran an antibiotic without actually connecting it to the patient, effectively infusing their matress I, along with my house supe and 1 other nurse, contributed to an error where a pt received a numbing throat spray that was the wrong concentration, and was in fact not meant for enteric use at that formulation. I was the one who actually administered the med, but the other two helped me get it and double-check the order when it wouldn't scan in High potential for harm: In addition to the above incedent, I have also flushed a foley with tap water rather than sterile saline. Pt was already getting scheduled abx and did not develop a bladder infection Resulted in harm: I once failed to notice that a peripheral line carrying fent/prop had come out. The site was covered in tegaderm and wrapped in coban d/t the patients severe weeping edema (nothing stuck to him) and I didn't take the time to pull this back and visualize the catheter tip where it entered the skin during my assessment. The pt was nonresponsive but did buck the vent pretty bad without sedation. I kept going up without effect until I noticed the wet spot on the mattress, it may have been a few hours ultimately. I have learned from each of these and adapted my practice as a result. I report myself when necessary. Still, it feels pretty awful and I can't help but think others maybe don't make these kinds of mistakes.