Ugh stupid mistakes!!!


I work in an ICU and have been off my 10 week preceptorship for about a week. When I have one patient, things usually go really well. But when I have two... I feel like an idiot. Last time I worked I had two stable (but very busy) patients. I am on night shift, and had to hang dilantin. I drew up dilantin with a filter needle as my drug book instructed me to, but didnt use an in-line filter. Was this dangerous to the pt?

Also on another patient I was hanging a lyte replacement (mag sulfate I believe) My pt had two IVPB setups with just normal saline on each. He was sleeping and laying on both. I piggybacked the replacement in one of the lines, and ran it. When my pt woke up, he told me he had been laying on a wet pillow. Turns out I piggybacked the mag into the line that WASNT connected to my patient's central line, it was just laying underneath him :banghead::banghead::banghead::banghead: This was also the line I had used for Dilantin, and later realized (after being off shift for about 6 hours) what if this precipitates in line and the next nurse uses it to run more Dilantin? I feel like an idiot when I have two patients, like Im running back and forth against the clock. I always always always do my proper med checks, but its these other mistakes that make me feel like maybe Im not careful enough for the ICU...

Any advice?

allnurses Guide

ghillbert, MSN, NP

3,796 Posts

Specializes in CTICU. Has 27 years experience.

Report the errors? Maybe you need to remain on orientation for a while longer. Did you inform someone that the patient did not receive their meds?


48 Posts

Specializes in ICU, ED.

Once I figured out that it was leaking, it was still infusing. So I stopped it, switched the correct line to the patient and continued the infusion. I let the next shift RN know that a portion had leaked on the bed, and that a redraw of labs would be needed.

The pt who recieved dilantin that was filtered via needle not inline recieved the med with no problems.

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