Scariest thing you have found

Nurses General Nursing

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What is the scariest thing that you have stumbled across after following someone else?

I found that a Dopamine drip had been started and left on all weekend on my medical floor that had staffing ratios from 1-6, and 1-10 at noc. And that with the drip, B/Ps had only been documented every 4-6 hours.

I also found a heparin drip going at 50 cc an hour. It was supposed to be 13 cc an hour. Someone hit the wrong button...

Specializes in Critical Care and ED.

Just the other week I took over from a nurse (in ICU), and the patient had a temperature of 103. When I look I discover that he had 2 blankets on which I remove. When I pull them back I discover an aluminum space blanket underneath!!!

I attend report of a young patient who had had a diabetic ketoacidosis coma in ICU. It was handed over that she was on an SIMV rate of 10, but when I check it is set at 0.5 and the patient is tachypnoeic and diaphoretic, and very symptomatic. The nurse was a new nurse who had not been properly trained or supervised. I filled in an incident form for that one.

On the orthopedic ward, the ward manager forced a patient who had had a total knee replacement (uncemented) to get out of bed and walk. The poor woman was crying in pain, and the manager told her if she didn't walk to the table, she would make her sit on a commode in the middle of the unit and make her eat her dinner there. As she got back into bed a cracking noise was heard, and she fractured her new prosthesis. There was an official complaint, but as usual the manager got off. She placed blame on a student nurse who was innocent. I hated that woman.

Specializes in Critical Care and ED.

May I add, that if you are worried about making a mistake then make sure you check everything thoroughly. It may sound obvious but a good place to start is right there at hand over report. Check all your infusions at start of shift...rate, content and site. That way if someone else has made a mistake you have discovered it early. Imagine discovering someone elses mistake 5 hours into your shift! Try explaning that one away! Check your emergency equipment, and always double check your drugs. Never rush and always think before you do anything.

Just recently I thought I had checked an ambu bag at start of shift. I checked the O2 worked and I checked the bag inflated, but we had a code and then I discovered that someone had flipped the connector back to front and it would not fit on the ET tube. I'll never do that again! Have faith in yourself and your own abilities and never attempt to do anything you are not familiar with. It's always better to ask.

Originally posted by LilgirlRN

This happened to my son.. he's in Florida with my mom and my nephew when he was 18. Open tib/fib fx, worst xrays I've seen and I work the ED. Talk to the ER nurse in Florida at the county hospital they took him to because he didn't have his insurance card on him. She assured me that the orthopod was 'the best". They took him to surgery, he was just coming back to his room when we arrived. I asked to see the post op films, they were no different than the pre-op!! Took him home the next day and went to see a real orthopod, had to wait 5 days for surgery to put a titanium rod in his leg because it was infected. All they did in "surgery" in Florida was swab the thing out with betadine and put a posterior splint on!!!

WTF???:eek: :eek:

Originally posted by hoolahan

At line change, the nurse hung two dopamine drips instead of the dopa and dobutamine. The drips were double concentrated because the pt had renal insuff. So the dopa was supposed to be like 2.5cc/hr or 2 mcg/kg/min and the dobut was running at 10 mcg/kg/min. So when she hung the dopa instead of the dobutamine, the pt became very tachy at change of shift. She was calling doc and they were initiating bolus of cardizem and she was readying a drip when I discovered what she had done.

The kick in the butt was, the pt son was there, and he was praising her up and down to me about how she had picked up on her father's change in condition and acted so quickly on his behalf, he was so impressed w the care his father got. Ha!!

This man was a dean of a lg university, and he offered her a BSN education for no cost!! Do you believe she had the audacity to accept it???? I would have been so embarrassed, I could never in good conscience have accepted that knowing that my error could have killed the man!!! Some people have no shame!!

Didn't you report it? Could you have written an anonymous letter to the family telling them the cause of the pt's problem?

This situation blows me away

Specializes in Obstetrics, M/S, Psych.

A psych patient had just been returned from an elopement. We strip searched her and checked for contraband, but had missed the razor blade she had placed between her butt cheeks. Shortly after we let her go back onto the unit, a co-worker and I found her cutting her throat in the bathroom. She barely missed her jugular vein and luckily made a full recovery.

By sbic56

but had missed the razor blade she had placed between her butt cheeks.

:chuckle

I can imagine that's the last place you would have wanted to inspect.

Didn't have a student around huh?...................Hey soandso, want to learn a new procedure?

Originally posted by sweetbaby

a very cold, very purple, very stiff 65 yo full code that had just been checked 15 min ago by the night NA going off duty.:confused: :o

Came in one morning and got report on a colon CA pt. RN told me she was breathing funny, kinda gasping. That was the first room I went into and found her in Cheyne-Stokes, pulse 40 and no BP. DUH!!!!!!

Another from the "Thank Goodnes I Walked in That Room" file, NA giving a pt a bed bath was to apply Nystatin to pts groin. She had a tube of NITRO in her hand!

:eek:

Originally posted by Rocknurse

I attend report of a young patient who had had a diabetic ketoacidosis coma in ICU. It was handed over that she was on an SIMV rate of 10, but when I check it is set at 0.5 and the patient is tachypnoeic and diaphoretic, and very symptomatic. .

I didn't know you could set a rate that low!:eek:

Specializes in Critical Care and ED.

Well, 0.5 is basically off!

Specializes in Obstetrics, M/S, Psych.
Originally posted by Peeps Mcarthur

By sbic56

:chuckle

I can imagine that's the last place you would have wanted to inspect.

Didn't have a student around huh?...................Hey soandso, want to learn a new procedure?

:rotfl: a golden clinical moment missed, I'm afraid!

:roll

Yes,that's right. If a student fails to get that checked off during their rotation that semester, they must complete a make up with the instructor demonstrating the procedure, and be shown to have demonstrated the skill before they are allowed to be passed.

:chuckle

Specializes in Obstetrics, M/S, Psych.

Peeps, you are evil to the core.:devil:

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