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.
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.
I always seem to rely on nurses report and now I'm finding out that I shouldn't and should check stuff on my own. My night nurse told me she didn't find the order and it's not in the chart so I asked the doctor when he turned up that day and he showed me where it is in the chart and it was not even hard to find. Embarrassing!
I unzipped a body bag after a dead patient made respiratory efforts...after the massive amount of Epi kicked in. He"lived" 2 more days ...dead on a vent. So sorry , Al.
He was most certainly NOT gasping for air. His autonomic nervous system kicked in ( from the epi) and made weak inspiratory efforts.
He was end stage COPD, already suffered enough and never should have been coded in the first place. To re- code him , let him linger 2 days on a vent was cruel.
Yep. Once somebody is dead enough for a body bag, it's a good idea to leave him in it. I have never seen that work out well. (I had a lady who was pretty darn close to dead when we sent her to the OR from the ICU and declared dead after flunking surgery. While they were waiting for the orderly to take her to the morgue some med student wandered in and reached into her open chest to practice open heart massage. Damned if it wasn't sorta moving anyway, he screamed, and she got sewn up and brought back to us. But not for long. Again, sorry, Marie.)
My first and biggest mistake was as a nursing student.
The RN I was working with had no interest in communicating with me from the start of the day. When it was time to give meds I checked the chart and saw the meds weren't given yet. I checked with the RN who verified she hadn't given them so I figured I was good to go. I gave the patient his meds then when I went to chart I saw the meds were suddenly charted as given. My heart was in my throat. I brought this to the RN's attention who said she had already given this patient his meds and that I "misheard" her - which I definitely did not - she was just not listening to me and brushing me off the same way she had been all day long. Turns out she HAD given the meds and charted late.
The kicker was that this patient was not entirely lucid - but he did say to me, "Oh, didn't the RN already give this to me? Oh well, go ahead!" I didn't think anything of it because of his mental status - but sure enough, he knew what he was talking about.
Fortunately it was some mild pain meds so THANKFULLY, other than feeling a little extra happy, there were no side effects.
While I was devastated to have made a med error ALREADY in my career, now I'm glad I "got it out of the way" early. I certainly won't be making the same mistake again and will LISTEN to my patients and triple check!
Many mistakes but I've learned from every one. Those that keep with me.
1) Gave 25mg PO metoprolol instead of 12.5. I check the MAR but overlooked the part that said 1/2 tab.
2) 1 of my patients had to go to MRI at change of shift. The Resource nurse who travels with patients was pregnant so she couldn't go. The Charge RN arranged for the Resource RN to cover the other patient and the oncoming RN would go to MRI instead. I gave report at change of shift to the Resource RN. Well after that I left, the Resource RN did too and left the patient with no RN covering. No one realized it until 0100 in the morning (I left at 1900). The Resource RN denied she ever took report and I was then accused of patient abandonment even though the Charge RN vouched for me that was the plan and the Nurse Manager saw me "talking to her (Resource) but didn't know what it was talking to her about". I learned to always write "Care endorsed to xxx using SBAR format" in the EMR after giving report.
You are not the first and wont be the last but your mistake will help improve your own and others practices and policies. We had a similar incident recently too in the SCN and the person involved felt terrible but totally owned up and it has made us all more vigilant. It doesn't matter how experienced or inexperienced you are, we are all human and all make mistakes but that is how we learn and get better. Thanks so much for sharing.
I've learned to never ask questions on Allnurses! Biggest mistake of my career so far hehe.I think my biggest mistake was not working in med surg first. I became an RN after being an lpn for 4 yrs,but lo and behold the recession came in 2008,the same yr I got my Rn license,so I guess you can figure out the rest.I moved,was willing to travel,etc but got nowhere.Now as a result,I'm locked out of a wider variety of jobs. The prison doesn't want to hire nurses with no med surg backround.
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sammiesmom
144 Posts
I always seem to rely on nurses report and now I'm finding out that I shouldn't and should check stuff on my own. My night nurse told me she didn't find the order and it's not in the chart so I asked the doctor when he turned up that day and he showed me where it is in the chart and it was not even hard to find. Embarrassing!