What's the biggest mistake you've ever made as a nurse? What did you learn from it?

[Mini-Murse]

If you feel comfortable posting to this thread, awesome. If not, no biggy!

I was wondering what the biggest mistake you've ever made in your nursing career has been. It could have to do with drug dosage or administration, or forgetting something, or even something as simple and innocuous as saying something to a patient or colleague before you could stop yourself!

The reason I think this thread is a good idea is that it shows that we're all human, we all make mistakes, and it will help us learn fro each other's mistakes, especially me and my fellow students, and ease our nerves a bit, so we know that we're not the first to ever take 15 tries to lay a central line or need 5 minutes to adjust an IV drop, but instead we're just part of a larger community who's support we can count on!

To be fair, I'll start.

I was working in a pharmacy, and a patient was prescribed 2.5mg Warfarin. I prepped the script properly, and accidentally pulled a bottle of Warfarin 5mg. I counted out the proper amount of pills, and bottled em up, passed it to my pharmacist for verification. She verified as accurate, and we sold the medicine to the patient. The patient's wife called a few days later and talked to the pharmacist who verified (who was also the pharmacy manager), and we discovered the mix-up. Luckily he hadn't taken for very long, but it terrified me. I could've been responsible for someone dying because I didn't double and triple check the meds. I got reprimanded, and she pharmacist got nothing. (this was also the same pharmacist who misplaced a full bottle of CII meds for 48 hours - she found it behind some loose papers on her desk)

I learned that there is no detail too little to double/triple check in medicine. I learned that it's never acceptable to "get in the zone" and work on reflex, and that every action you take has consequences; some more deadly than others.

[Heidi the nurse, BSN, RN]

This is actually a decision I made in nursing school, and it might have radically changed my life if I had gone in that direction. I took an elective class my last semester of nursing school where the professor and I went out and did art therapy in a shelter for homeless women and their children. In the past, his students had worked with the kids, but we both thought it would be interesting to work with the women instead. But the most interesting thing was I put up an "art wall" - a 10 foot piece of butcher paper that they could draw on between my visits. I wrote up instructions, starting off in a behaviorally neutral color. As the weeks progressed, I used different colors, and when I used red and black, the drawings became very "odd", violent, and dark. It was really interesting. My professor thought looking into this more in depth would make a great Master's thesis.

Well, I was one of those that though you should get some experience under your belt before getting your Masters. So I did, decided I didn't like psych, got married, had kids, got divorced. But every once and awhile I run across the drawings those women gave me to thank me for visiting them and I wonder "what if"...

So, 20 years later, I am going back to school :) Pediatrics have been my bag for the last 10 years, but if I could find my passion for art therapy and psych again, who knows, maybe I will end up doing that for my thesis.

[Mini-Murse]

Thanks Heidi, but that's not exactly what I was expecting as a reply That doesnt sound like a mistake, it sounds like you really found the right path for you!!

[klone, MSN, RN]

I gave colostrum to a baby that was not from that baby's mother.

Lesson learned - ALWAYS ALWAYS check meds and labels. Don't rely on another nurse's judgment and accuracy.

[Heidi the nurse, BSN, RN]

Thanks Heidi, but that's not exactly what I was expecting as a reply That doesnt sound like a mistake, it sounds like you really found the right path for you!!

No - I realize you were looking for something like med errors or something like that. But I figured it was pretty simple and innocuous but made a very big difference in my life. You don't only learn from your mistakes :)

[Mini-Murse]

You don't only learn from your mistakes :)

So damn true, it bears repeating

[A&OxNone, MSN, RN]

Not a SERIOUS nursing mistake, but def embarassing...

Dont ever assume somebody is the father or son or whatever. ALWAYS ask how they are related. Some of my most embarassing moments is when I say something about "your dad" and the patient says,"um, that's my boyfriend"... or whatever.

SOOOOOO want to put my foot in my mouth!

[sharpeimom]

i worked on a locked psych dept. and quickly learned three lessons:

1. never wear a necklace, earrings, etc. to work.

2. never turn your back on a patient, mo matter how normal s/he appears.

3. never try to have a conversation with a 400#+ h*ll's angel pt. alone. i am 5'4" and weighed

about 110#, and was absolutely no match at all. he grabbed me and suddenly i was airborne.

he yelled "make a wish, b*tch! he had grabbed me by my right shoulder and left hip. fortunately

three large male aides heard him, then heard me scream.

[FancypantsRN]

i worked on a locked psych dept. and quickly learned three lessons:

1. never wear a necklace, earrings, etc. to work.

2. never turn your back on a patient, mo matter how normal s/he appears.

3. never try to have a conversation with a 400#+ h*ll's angel pt. alone. i am 5'4" and weighed

about 110#, and was absolutely no match at all. he grabbed me and suddenly i was airborne.

he yelled "make a wish, b*tch! he had grabbed me by my right shoulder and left hip. fortunately

three large male aides heard him, then heard me scream.

wow! you must have some amazing compassion to be able to return to work after that! i hope you are/were ok.

[sharpeimom]

wow! you must have some amazing compassion to be able to return to work after that! i hope you are/were ok.

thank you! my mom used to say i had a scream like an air raid siren when i was two and mid-tantrum, and i think that same basic sound re-emerged that night. that night is living proof that my orientation

was not long enough or indepth enough. he dislocated my shoulder and that night was the beginning of a

very torn rotator cuff.

as far as returning to my job, i was in my twenties and not about to let some big fat bully think he won.

when you work in a state psych hospital you know when you sign on that you'll meet some real wingnuts.

(that was one of my dad's expressions.)

[greatshakes]

I think I would be scared to be on a locked pysch ward with any patient. When I was working at a nursing home we had to lock doors behind us and I think that always put me off mental health nursing although I don't have any trouble with dementia patients. The mistake I worrry about was one where I warmed a heat pack for an aged lady in pain and didn't heat it for all the required time. I placed it in a pillow case and lay it over the patient's nightie and dressing gown to make sure it wasn't too hot. After five minutes, I approached the lady and asked if the heat pack had helped. I was told everything was perfect. I went to break and was shown a red mark on the patient's back when I got back. I apologised and admitted to giving the lady the heat pack and went to fill in an incident report. I was told I should have heated it in 20 second bursts. The pack didn't say that, just to heat for three minutes. Talk about feeling like an idiot. I learnt something though, just be very careful who you trust, one might

give you a recommendation while another two are trying to make mischief.

[jeffsher]

I was giving multiple chemotherapy meds to a 2 year old for her ALL, mixed syringes up, and mistakenly gave a hep flush IM (was supposed to give L-Asparaginase). I was fortunate that I had already given the Vincristine IVP and not mixed up THAT syringe.

I was just on the receiving end of a major med error last week. I am on Tacrolimus for a kidney transplant and had a recent foot infection leading to Orthopedic surgery. My foot ulcer grew out an opportunistic Candida, and after consulting with ID, the Ortho PA rx'd Fluconazole. When I had my monthly labs done, I was in acute renal failure and Tacrolimus toxicity. The PA surely had a warning of a major interaction between Flucoazole and Tacrolimus, but apparently ignored it, and never consulted with the Transplant doc who manages my Tacrolimus.