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've done that before and got busted! I got wrote up for false documentation because I didn't look at the site. My DON was really cool about it and It was seriously my second day working as a nurse so I was very much on the clueless side of things but she taught me two very important lessons that I have carried and kept in high regard ever since. 1) False documentation is a big no no and they can yank your license from you in a heartbeat for it. 2) Luckily, it was normal saline. If it would have been say a K rider or Vanc or if I would have pushed the Phenergan she had ordered, those meds can and will cause tissue necrosis which could have led to major infection and damage. When your new you think something as silly as glancing at someone's iv site is no big deal but one thing about nursing, it is always the little, fundamental things that were drilled into our heads since the first day of nursing school that can cause lots of damage including losing your job and/or being reported to the board. I'll tell ya though, I haven't made that error since and ill never forget it. :)
I know that the laws vary by state but here in WV, you do not touch an IV in nursing school at all. You learn how to spike and hang bags and work the pumps etc but yeah, we are trained on the job or our employers send us to a 3 day class and we get certified in IV's PICC's Midlines for two yrs. I actually learned IV's as an LPN working on a Med Surg floor.
You poor thing! LOL! I've been in your shoes and I know exactly how you feel...but honestly, those are the kind of dumb mistakes that a new nurse makes and your higher ups know this. I did some of those very things. But, when I forgot to turn on the pump after I hung the piggy back, I got a med error on me because my DON happened to see it and it was like two hrs overdue...A girl stuck a fent patch in the one of those little cubbies and got fired for it. It is really scary because nursing is a heck of a learning process and you don't learn hardly anything you need in nursing school. Wait until this time next year after you've worked for a full year and you will be a completely different nurse. You will know how to think better and you'll have a routine established. But like I said, some of those things you mentioned above are considered med errors and the blood sugars not getting checked are some kind of infraction as well and honestly, the healthcare field has such a big turn over because facilities will fire nurses for mistakes like that, even though theyre so stupid and were all human....im speaking from experience. I got screwed really bad and fired for accidentally signing off a neb tx and then forgot to turn the machine on. And just the week before I was in for my evaluation with my DON and administrator, and HR rep and they bragged and bragged on what a wonderful nurse I was and how they wished the other employees would take notes and they went on and on and made me feel so good then i got canned over albuterol the next week...that was devastating...now granted, they fired 15 other people on the same day they fired me because we had a really bad state survey and corporate decided to just wipe out the whole staff. They escorted the DON to the time clock and woouldnt let her get her stuff and she had worked there for 37 years!! Anyways thats way off the subject but the best advice I can give u is even though it takes that one extra second to double check or to ask someone, it is worth it. I had to start double checking myself for a while when I was a new nurse because like you said, my hands would be full of meds so i'd ha-15mg the iv fluids and meds on the pole first then give the PO's etc and then id totally forget to turn them on so I had to start making two trips or if I was absolutely swamped, id set the alarm on my phone with a reminder that said "go check IV poles" it would go off about 10-15 mins after my meds were passed and there were several times I went in and found them. If I would have got caught without one running and got another med error write up, in that facility, it was grounds for dismissal so I had to do whatever it took to make sure I had everything done and administered correctly and on time. You'll be fine!! Just know, the mistakes you spoke of in your post, you'll never make them again!!! haha
Pts blood sugars were really high all day... Couldn't figure out why...called the doc, trying to figure it out. Re check the MAR....I have her sliding scale humalog in the morning but missed her 44u of lantus...*facepalm* it was written under the sliding scale and beside the sliding scale it says *see diabetic profile* so I always turn to that page and miss anything underneath. Turns out I had missed it the day before too. I was in my final placement as a student and my preceptor gave me crap for it!
I gave PRBCs to a micropreemie (all 10mL of it) over 30 min instead of 3 hrs. Just missed one zero on the pump. The MD wasn't mad, it actually benefitted the baby because she was hypotensive.
I know it's common practice in SNFs but the standard of care is to chart the DOSE, not some fraction of a pill unit. What happens if the pharmacy gets a source of 12.5mg pills and nobody notices, but they are so used to cutting his pills in half they are now giving him half doses? Why do we teach med math, anyway? See if you can get this changed in your pharmacy p&p/medical therapeutics committee meeting.
reminds me of the time I had this one pt who was post op PEG placement. It was like her 4th or 5th PEG placement because each one prior had some sort of complication. Additionally, all of these PEGs were placed by the same surgeon, who also happens to be the most rude MD you could possibly imagine. So I go to administer her meds and flush the tube and notice all the water is leaking out, and there is a huge gaping hole in the tube!! Not sure if it was caused by me flushing the tube or how on earth that happened. Of course, I am terrified to call the surgeon. But this is how it went down: "What do you mean there is a hole in the PEG tube?" "Dr, I'm not sure how it happened." "Well I will be up to take a look at it." So he shows up a few minutes later, and asks me to show him the PEG tube. He takes a look at it and was like "well, guess we can't use that anymore." My reaction was one of mostly relief that he didn't chew me out in front of the pt. but felt so bad for the patient and the embarrassment of telling them what happened.
my worst and first mistake that comes to mind was running a piggyback antibiotic into the PPN line, like a dummy. luckily, the patient didn't have a reaction.
As a student in clinical, I gave a SQ injection of Octreotide into a pt.'s deltoid. As I was administering it, he was saying, "Ow! That burns! Ow! Hurry!" Well... lo and behold, even though I had looked up the med for precautions, contraindications, etc., I failed to look at the IM implementation, which says specifically "avoid using deltoid site due to pain of injection." That will never happen again.
I had a patient in ICU who suddenly developed a unilateral fixed dilated pupil, I called the critical care attending, he came flying up... I had TOTALLY FORGOTTEN THAT THE OPHTHALMOLOGIST CAME AND SAW THE PATIENT 15 minutes before to dilate his pupil and check his macula and vasculature... I even had a conversation with him about dilating the patient's pupil. I felt like SUCH a moron.
Oh and while in training I had an out of control patient... My preceptor said, "be really careful, you don't know what these people will do" I'm like "ya ok it's oral care, I got this"... Well... she didn't like oral care, she became incredibly ****** off and extubated herself (while in soft restraints) faster than I could say Ativan... I screamed for help. I got crap for it until I transferred out of the unit.
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Emcat87
13 Posts
I've done that before and got busted! I got wrote up for false documentation because I didn't look at the site. My DON was really cool about it and It was seriously my second day working as a nurse so I was very much on the clueless side of things but she taught me two very important lessons that I have carried and kept in high regard ever since. 1) False documentation is a big no no and they can yank your license from you in a heartbeat for it. 2) Luckily, it was normal saline. If it would have been say a K rider or Vanc or if I would have pushed the Phenergan she had ordered, those meds can and will cause tissue necrosis which could have led to major infection and damage. When your new you think something as silly as glancing at someone's iv site is no big deal but one thing about nursing, it is always the little, fundamental things that were drilled into our heads since the first day of nursing school that can cause lots of damage including losing your job and/or being reported to the board. I'll tell ya though, I haven't made that error since and ill never forget it. :)