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.
Day two on orientation in the NICU (my first job as a nurse), I assessed an IV all morning and didn't see anything wrong with it. The site wasn't red or leaking....but the leg was swollen, badly. The baby was getting Hyperal and Lipids (TPN) which tears apart veins and tissue really bad...learned that quickly. I wasn't assessing the leg compared to the other one, so I saw a chunky baby leg and didn't think anything of it...but this was a premie with chicken legs. By the time it was caught, the baby lost most of the skin on the top of his foot and everyone who saw it said it was the worse they'd ever seen. My preceptor felt awful because she didn't check behind me and I was brand new...but I felt worse. It was horrible. It was probably only three hours worth of TPN that had infiltrated but it was so rough.
Now I watch my IVs like a HAWK! I'll pull it and restart it in a heartbeat if I don't like it!
Also, I've become a big advocate for putting in a PICC for long term TPN, which is standard protocol, but not always done in a timely manner.
Also, about starting IVs, I never learned about it in school..never did the fake arm thing. We were told our hospitals would want to train us themselves and/or would have an IV team to do them.
I committed and error during my graveyard shift and that was the reason why I ended up here to know if someone committed the same mistake like I did but alas, I found none.
Anyways, my mistake was totally idiotic in nature.
My patient was on NPO but I gave her 30cc of water and her medicine but it wasn't just an ordinary medicine, it was an oral hypoglycemic agent Glimepiride and she was scheduled for a Fasting Blood Glucose at 6:00 AM. I gave her the medicine at 5:00 AM.
I was so stupid that I even reminded her not to take anything before her blood is withdrawn but I ended up eating those words. When she was done taking her medicine, she then asked me about her NPO status and then it dawned on me. I was like splashed with cold water all over my body. I don't know how to react in front of her. I even forgot how I responded to her question. All I remember was I went directly to my preceptor and she was horrified but she wasn't mad when I told her about it. We then went to our team leader. She was calm and she wasn't saying anything. She then told my preceptor to call the lab right away to get her blood. My guilt doubled when they told the lab that the reason why they would draw the blood early is because the patient couldn't wait anymore and that she was hungry. They were forced to tell a lie on my behalf and I couldn't help myself to feel worse about it. I think it was around 30 to 45 minutes after the medicine administration that her blood was drawn out.
I just hoped that there would be no significant difference but I doubt that would happen. T_T
Specializes in Acute Care - Adult, Med Surg, Neuro.
I committed and error during my graveyard shift and that was the reason why I ended up here to know if someone committed the same mistake like I did but alas, I found none.
Anyways, my mistake was totally idiotic in nature.
My patient was on NPO but I gave her 30cc of water and her medicine but it wasn't just an ordinary medicine, it was an oral hypoglycemic agent Glimepiride and she was scheduled for a Fasting Blood Glucose at 6:00 AM. I gave her the medicine at 5:00 AM.
I was so stupid that I even reminded her not to take anything before her blood is withdrawn but I ended up eating those words. When she was done taking her medicine, she then asked me about her NPO status and then it dawned on me. I was like splashed with cold water all over my body. I don't know how to react in front of her. I even forgot how I responded to her question. All I remember was I went directly to my preceptor and she was horrified but she wasn't mad when I told her about it. We then went to our team leader. She was calm and she wasn't saying anything. She then told my preceptor to call the lab right away to get her blood. My guilt doubled when they told the lab that the reason why they would draw the blood early is because the patient couldn't wait anymore and that she was hungry. They were forced to tell a lie on my behalf and I couldn't help myself to feel worse about it. I think it was around 30 to 45 minutes after the medicine administration that her blood was drawn out.
I just hoped that there would be no significant difference but I doubt that would happen. T_T
We have a protocol for fasting patients. I've never had one except for patient's NPO for surgery. Either way the physicians usually say what to do about certain medications. Many times we give patients their blood pressure medications with a small sip of water prior to surgery.
With insulin and oral diabetic medications, we are instructed to contact the MD for clarification of dosing when a patient is NPO. Many of our patients aren't on oral diabetic medications because of recent contrast dye or because physicians prefer insulin when a patient is in the hospital.
I guess your mistake is more that a nuisance to the patient if she has to repeat her fasting, also be sure to clarify if how a patient should take their diabetic medication if they are NPO. In her case, I would have probably waited until the lab had been drawn, had her order her food, and then give it to her if appropriate.
Also remember that if a patient is diabetic and NPO MD's often want blood glucose checks Q4-6H hours, particularly if they are on diabetic medication or insulin.
I had a patient with prostate issues. I was told by the prior nurse that the patient has the prostate cancer as well. Not as a bedside report!
Anyway, when I was giving report to a different nurse at the end of my shift, we did bedside report. And I told the nurse that the patient had prostate cancer, in front of the patient. Guess what? Patient got freaked out saying "what! I don't have cancer!, etc". Doctor happened to come in and witness some of that too by the way. The reality is, patient didn't have the cancer. When we left the room, doctor approached me and said that the patient didn't have a cancer and I shouldn't have said that. Fortunately, he was one of the very nice doctors, and I told him that that was what I was told too.
I felt so embarrassed and dumb in front of the patient. But I still blame the previous nurse who told me that.
This is why I never rely on what another nurse tells me in report as fact. I always do my own checking/investigating as I too have been burned before by inaccurate information.
I hung heparin on a pt. Who just came back from having a heart Cath. Could have been bad but another nurse came in to help me get the pt. Settled and noticed what I did. She only got about 2 minutes worth of heparin.
Ok so I am working in LTC and was training a new nurse. She had trained several days and was ready to pass meds on her own with just supervision. She was doing well until she told me "I think I gave meds to the wrong patient. I find out she gave bed A's meds to bed B. I knew that bed A was on a lot of seizure meds and blood pressure meds so I panicked. I ran down the hall to grab our DON and then learned one of the most important lessons about giving the wrong meds. CHECK THE PATIENT'S ALLERGIES!!! The DON was good enough to help walk me through the procedure. After checking allergies I called the doctor. After giving him a frantic report he assured me that she would be fine but wanted us to check her Blood Pressure hourly and push fluids. He then asked me "are you OK?" Bless his dear soul, he could tell my voice was shaking and I was a wreck. I then had to call her family and update them which was also hard because they were longtime family friends.
Even at 101 years old she was fine and lived until she was 103, but I won't forget that feeling.
I also worked in a facility that had medication aids who weren't even trained as CNAs. One lady gave a patient her "own" dose of insulin instead of the patient's sliding scale and had the audacity to tell me "well that is the dose I would give myself". I didn't stay there much longer because it just wasn't safe. She wasn't even fired and I had to fight to get her removed from passing meds after so many errors.
Specializes in Emergency/Trauma/Critical Care Nursing.
Ok so I am working in LTC and was training a new nurse. She had trained several days and was ready to pass meds on her own with just supervision. She was doing well until she told me "I think I gave meds to the wrong patient. I find out she gave bed A's meds to bed B. I knew that bed A was on a lot of seizure meds and blood pressure meds so I panicked. I ran down the hall to grab our DON and then learned one of the most important lessons about giving the wrong meds. CHECK THE PATIENT'S ALLERGIES!!! The DON was good enough to help walk me through the procedure. After checking allergies I called the doctor. After giving him a frantic report he assured me that she would be fine but wanted us to check her Blood Pressure hourly and push fluids. He then asked me "are you OK?" Bless his dear soul, he could tell my voice was shaking and I was a wreck. I then had to call her family and update them which was also hard because they were longtime family friends.
Even at 101 years old she was fine and lived until she was 103, but I won't forget that feeling.
I also worked in a facility that had medication aids who weren't even trained as CNAs. One lady gave a patient her "own" dose of insulin instead of the patient's sliding scale and had the audacity to tell me "well that is the dose I would give myself". I didn't stay there much longer because it just wasn't safe. She wasn't even fired and I had to fight to get her removed from passing meds after so many errors.
I bet with those seizure meds on board that patient slept well that night! Lol
Specializes in Med Surg, Perinatal, Endoscopy, IVF Lab.
Okay, I have made insignificant errors along the way... but here's the worst. I was helping out our church by being the camp nurse for kid's camp one year. Lots of kids getting allergy meds and stuff like that. Rural setting, nothing computerized, everything on cards, etc. We had one on several seisure meds and one diabetic (who was very attentive to her insulin). Anyway, one night I was passing meds after chapel and my blond seisure med girl comes up to the desk and I make my first mistake. "Oh are you Abby such-and-such here to get your meds?". She says "yes" tentatively and I count out and hand her her cup of seisure meds. It wasn't the right girl. This girl looked very similar to her but it wasn't her. Turns out, this girl was just coming up to get a cough drop, but she was shy and just answered yes to my questions. Fifteen min later, the REAL girl comes up to get her seisure meds and my eyes went wide I raced to her info sheet to sort it out and look for allergies. I then went to find the girl I mistakenly gave meds too. She was tearful and feeling bad by now. I velcroed her to my side as we went to find the director and tell him what happened. He was nervous. I had to call her dad and explain the situation. We took her to the ER where they observed her overnight and then released her. Here's the worst part... nobody even came to see her at the ER. She was living with a dad that didn't take much interest in her and was happy to get her out of his hair for a week each Summer. He says "call me if it's anything serious". It was a HOT MESS and I will never get over it. Ugh. It all ended well, but it was scary.
Okay, I have made insignificant errors along the way... but here's the worst. I was helping out our church by being the camp nurse for kid's camp one year. Lots of kids getting allergy meds and stuff like that. Rural setting, nothing computerized, everything on cards, etc. We had one on several seisure meds and one diabetic (who was very attentive to her insulin). Anyway, one night I was passing meds after chapel and my blond seisure med girl comes up to the desk and I make my first mistake. "Oh are you Abby such-and-such here to get your meds?". She says "yes" tentatively and I count out and hand her her cup of seisure meds. It wasn't the right girl. This girl looked very similar to her but it wasn't her. Turns out, this girl was just coming up to get a cough drop, but she was shy and just answered yes to my questions. Fifteen min later, the REAL girl comes up to get her seisure meds and my eyes went wide I raced to her info sheet to sort it out and look for allergies. I then went to find the girl I mistakenly gave meds too. She was tearful and feeling bad by now. I velcroed her to my side as we went to find the director and tell him what happened. He was nervous. I had to call her dad and explain the situation. We took her to the ER where they observed her overnight and then released her. Here's the worst part... nobody even came to see her at the ER. She was living with a dad that didn't take much interest in her and was happy to get her out of his hair for a week each Summer. He says "call me if it's anything serious". It was a HOT MESS and I will never get over it. Ugh. It all ended well, but it was scary.
You know... I have to say that I don't think that's your fault and that you can stop letting it hang over your head. I know it was scary, but you can't routinely expect patients to lie to you when you ask them who they are. It's not like kids at camps have identification bracelets on like patients do. You can't make sure they are being honest with you, and you did a great job fixing the problem. Kudos to you!
Reading this thread is both reassuring and scary as a new nursing student....reassuring as I can see that everyone makes mistakes and scary that I know I'm bound to have plenty of moments in my future career where I'm gonna be terrified and kicking myself because I made an error.
I'm only in my 5th week of school and I've already had a mistake in clinicals that I keep thinking about/freaking out over. My 3 day in the hospital I gave a pt who was on thickened liquids only a drink of water. He turned a little red and coughed for a while but as far as I know he was fine....the Pct walked in on me when I was about to go tell the nurse he was coughing. Luckily she only chewed me out a little but and was actually pretty nice, saying "you learn from your mistakes" and telling me about a mistake she made. My preceptor didn't even really say anything, I don't think she was too mad but I couldn't really read her...Anyway I still feel terrible.
I raced to her info sheet to sort it out and look for allergies. I then went to find the girl I mistakenly gave meds too. She was tearful and feeling bad by now. I velcroed her to my side as we went to find the director and tell him what happened. He was nervous. I had to call her dad and explain the situation. We took her to the ER where they observed her overnight and then released her. Here's the worst part... nobody even came to see her at the ER. She was living with a dad that didn't take much interest in her and was happy to get her out of his hair for a week each Summer. He says "call me if it's anything serious". It was a HOT MESS and I will never get over it. Ugh. It all ended well, but it was scary. 
katierobin23
147 Posts
Day two on orientation in the NICU (my first job as a nurse), I assessed an IV all morning and didn't see anything wrong with it. The site wasn't red or leaking....but the leg was swollen, badly. The baby was getting Hyperal and Lipids (TPN) which tears apart veins and tissue really bad...learned that quickly. I wasn't assessing the leg compared to the other one, so I saw a chunky baby leg and didn't think anything of it...but this was a premie with chicken legs. By the time it was caught, the baby lost most of the skin on the top of his foot and everyone who saw it said it was the worse they'd ever seen. My preceptor felt awful because she didn't check behind me and I was brand new...but I felt worse. It was horrible. It was probably only three hours worth of TPN that had infiltrated but it was so rough.
Now I watch my IVs like a HAWK! I'll pull it and restart it in a heartbeat if I don't like it!
Also, I've become a big advocate for putting in a PICC for long term TPN, which is standard protocol, but not always done in a timely manner.
Also, about starting IVs, I never learned about it in school..never did the fake arm thing. We were told our hospitals would want to train us themselves and/or would have an IV team to do them.