Scariest thing you have found

moonshadeau, ADN, BSN, MSN, RN, APN, NP, CNS · May 31, 2003

I was sitting at the desk on day and another nurse CASUALLY wanders up to me and asks what she should do since her heart cath was bleeding...um pressure, now!

moonshadeau, ADN, BSN, MSN, RN, APN, NP, CNS · May 31, 2003

And I do want to add that we all try to be the best that we can. No one intentionally (I hope) would want to find themselves being the causitive agent behind some of these errors. But by sharing our experiences, hopefully we can learn from them and take the time to stop and think...

Dayannight · Jun 1, 2003

Have found antibiotic partials hanging on the wrong patient. Also had a patient with a PEG tube feeding that was supposed to be going at 50cc/hr found with the pump turned off, the tubing off the pump and the clamp wide open. That patient went into CHF and did not recover.......!!!

Also, when my one of my daughters was 10 yrs old, she was recovering from sinus surgery resulting from a really bad sinus infection. The day after surgery, the doc dc'd the IV fluids. The unit secretary thought that meant everything IV and pinked out the IV antibiotic (which was to continue for 8 days) as well. The nurse taking care of my daughter at the time didn't double check, and so she missed a dose (it was q 8 hrs). I wonder how many she would have missed if I hadn't known to check that order. (Working at the same hospital had its advantages.)

kids · Jun 1, 2003

I was working in a sub-acute facility...came to back to work after 4 days off to find a patient with frank blood in his foley bag...thick frank blood. Patient A&OX4, states has been like that since he stepped on his tubing 3 days ago. I checked the chart...every day for the past 3 days the SAME nurse documented that he had BRB per foley in the SAME note she documented giving him 5mg of COUMADIN.

This was not a case of being stretched too thin or being floated to an unfamiliar unit. The team was 9 patients (stable long-term trachs/vents) with 2 NACs and an RT. The nurse (happened to be an LPN) had been on the unit with (most of) the same patients for 2 years. She had no IVs (facility wouldn't even let LPNs assess a site or hang a fresh bag of maintenance fluids) and the RT did everything that involved the respiratory system-from inhalers to trach care. It was the one and only nursing job I have ever had where I got all of my work done and got to leave on time every day.

The patient went to the hospital. It took a week (and a Urologist) to get the bleeding controlled and to pump enough blood in to him to send him back.

I got written up for chewing her out.

Good_Queen_Bess · Jun 1, 2003

A long time ago, I heard a story of someone putting LACTULOSE down someones central line instead of the NG tube. YUK! Sticky veins!!!

gwenith, BSN, RN · Jun 1, 2003

NG down an IV has happened over here to a neonate. This is why a lot of NG tubign is made ot be incompatable with IV ends. Scariest thing I evers saw - gods I've seen my fair share form the patient connected to teh respiratory circuit that did not have expiratory line to the incorrect admixture of drugs.

Possibley one of the more "infamous" cases that occured here in Australia happened in NSW a few years back - new RN little clinical experience sent as agency to ICU. ICU EXTREMELY busy so accepted untrained staff. He gave oral Phenytoin IV ! Checked the dose with another nurse but of course she did not see him give it. PT died BIG inquest - outcoem not only was the nurse investicated but the other ICU staff on that night, the agency employing him and HIS UNIVERSITY LECTURERS WERE PUT ON THE STAND!!!!

Liddle Noodnik · Jun 1, 2003

Originally posted by moonshadeau
And I do want to add that we all try to be the best that we can.

When I oriented for my new job recently, they showed a movie about hospital errors. It was supposed to be the prelude to a discussion about "no blame" for medical errors. But what it did was have half a dozen nurses sobbing. It showed how pressured we really are (showed it REALLY well, so well that it could be any one of the places I'd worked in 23 years). The purpose of the class was errors but I felt like a raw open wound afterward; we could really KILL someone by our screwups! And whose fault? Not ours!

It showed a pregnant woman and her husband, both from Russia and almost unable to speak English, and she was having grave symptoms (major bleeding, major pain, etc.) and she kept getting passed from nurse to nurse to nurse and no one was calling the doctor even tho she was begging.

Then the surgeon started cutting even before the intubation was complete (for a c section). AND, the baby was given a wrong med. Both of them died. Talk about OVERKILL.

I wish there had followed a discussion of how to change the system instead of about medical errors/incident reports. they told us the purpose of the incident reports WAS to change the system, but I can't see that happening anytime soon.

I also thought it showed how much we need to join together, work together, speak up together, support each other as in support groups, etc.

The movie was MAJOR heartbreaking, and here you all are talking about similar things.

That movie made me want to quit, just like a thousand "nights from hell" have in the past. In fact I "retired" from nursing 3 times (the first time at 26 years old!) because of stuff like this.

Liddle Noodnik · Jun 1, 2003

Originally posted by kids-r-fun
I got written up for chewing her out.

See, there is rule number one of nursing: Don't be human and react. You must at all times be stoic and accepting that things are the way they are.

Jay-Jay, RN · Jun 1, 2003

The patient went to the hospital. It took a week (and a Urologist) to get the bleeding controlled and to pump enough blood in to him to send him back.
I got written up for chewing her out.

:eek:

Now, that IS scary!!

BTW, yes, 2/3 and 1/3 is the percentage of NS to glucose in the IV bag.

Coldfoot · Jun 1, 2003

The worst things I have seen........

Ok, the scariest this is walking into an ER Room and finding dirty "Mystery" sharps. Who knows where they came from, who left them there, or how long they have been there?

Had a Surgical resident atempt a chest tube on a stable, concious spontaniouse pneumo without any PN control (he was stopped as soon as ER Staff walked into the room).

Working as a paramedic, responded to "siezures" non-emergent and found pt in Status SZ's UNDER THE BED!!!!!!!! in an LTC. (Pt was s/p unwittnessed fall.)

Transported out of LTC after new RN gave D50 IM (She musta worked at pushing those 25cc's in)

There are some scarry people out there:eek:

Hellllllo Nurse, BSN, RN · Jun 1, 2003

Oder incorrectly transcribed as :

1000mg Vit K, IM qd X (I forget how many days)..

Even worse, although there is no such order, and the Vit K comes in 10mg/ml ampules, several nurses had signed this out as given.

I can imagine a "nurse" drawing up amp after amp into the worlds largest syringe, trying to get the "1000 mg" dose.

The order was supposed to be for B-12.

I did find amps of Vit K in the cart w/ several doses missing.

Pt turned out to be ok, because no one had actually given the pt anything, just signed that they did. Adm covered it all up, anyway.

they "lost" the incident report I filled out.

Hellllllo Nurse, BSN, RN · Jun 1, 2003

Originally posted by zoeboboey
Yes, I am aware of that, but still don't know what 2/3 and 1/3 is. Is that the percentage of sodium?

Same here. I know you hang blood w/ NS. But what are 2/3 and 1/3?

Are they hypotonic salines?