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'm still a new nurse and learning from my mistakes, but sometimes I feel like I'm the only one who makes mistakes. This post is great for boosting my confidence as I learn that we are all human! The first time I ever got in trouble with my manager was because a doctor told me over the phone that the patient would be having a laproscopic cholecystectomy the next day and to put that in the orders along with an order to get the consent. I put both of those orders in the chart, got the consent, and trying to do what I had learned, I went ahead and put in the order for the patient to be NPO after midnight for the procedure. Well several days later, when the patient is being discharged, I learn that the doctor was very upset and refusing to sign the patient's chart because he never gave orders for the patient to be NPO. True, he never gave that order, but the patient was having surgery, isn't that a given?! My manager informed me that if I ever did that again that I would be written up. Then she told me that next time I should just hold the breakfast tray, and not put the order in the computer. I was not the nurse for the next day, what if that nurse forgot.
My next mistake I got into trouble for was over labs. In this case the patient was a very hard stick, and it took 4 different nurses trying just to get an IV started on her the day before. The doctor ordered a couple of labs to be done on this day of my shift. I knew the patient was a hard stick, and I knew the patient would be going for dialysis later that day. So, I saved the labels for labs, and sent them with the dialysis nurse to be drawn there. Later in my shift I saw new lab results pop up on the screen, quickly glanced through them, then moved on. I assumed all of the labs were done after that, but never went in a really checked it good. The next day I received a call from my manager, on my day off, that the doctor was very upset and throwing a fit at the nurses station because the labs he had ordered were not done. I was told by my manager that the incident would be reported to administration, and never heard anything else after that.
I'm still a new nurse and learning from my mistakes, but sometimes I feel like I'm the only one who makes mistakes. This post is great for boosting my confidence as I learn that we are all human! The first time I ever got in trouble with my manager was because a doctor told me over the phone that the patient would be having a laproscopic cholecystectomy the next day and to put that in the orders along with an order to get the consent. I put both of those orders in the chart, got the consent, and trying to do what I had learned, I went ahead and put in the order for the patient to be NPO after midnight for the procedure. Well several days later, when the patient is being discharged, I learn that the doctor was very upset and refusing to sign the patient's chart because he never gave orders for the patient to be NPO. True, he never gave that order, but the patient was having surgery, isn't that a given?! My manager informed me that if I ever did that again that I would be written up. Then she told me that next time I should just hold the breakfast tray, and not put the order in the computer. I was not the nurse for the next day, what if that nurse forgot.
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Really?? I work med-surg and we put NPO after midnight orders in all the time for surgical patients if the physician forgets. If I know a patient is going for a lap chole at 08:00 and I am the night shift nurse, I won't be around to make sure the breakfast tray gets held. Dietary delivers even if there is an NPO sign on the door sometimes. If that patient were to have eaten, the surgery would have ended up delayed and gotten that surgeons schedule all out of wack. Would he have been happy then?
There are exceptions. For example, if the surgery won't be until afternoon the next day, and the surgeon didn't make the diet orders clear, I will call to clarify. What time was your patients surgery?
Once I had a 20 year old female AOx4 patient scheduled for hand surgery at 08:00 the next day. I made sure consent was on the chart, informed her of her NPO status after midnight, put a sign outside the door, wrote it on her whiteboard, ect...
I did not make sure there was an order for NPO. Dietary delivered breakfast, she ate, and the surgeon was livid with me. Day shift pointed out that he never put the order in, but the mistake was ultimately mine. Patients surgery ended up delayed and I heard about it when I returned that night. Lesson learned.
When in doubt, call. And after surgery always make sure the diet order is correct. I have heard of patients. NPO for days after surg because the physician forgot to write an order to advance the diet. But in your situation I fail to understand why the surgeon is making such a fuss. Did he WANT her to eat? Anesthesia will sometimes refuse patients who have not been NPO, even if the surgeon wants to proceed.
Had this happen in a situation where the pt came in with a severe hand injury (again with the hands!). I forget the details but basically he had been in prison, was out on some kind of weekend pass, and was going to have to go back on the next Monday. He had eaten shortly before the injury earlier that day, surgeon wanted to proceed, anesthesia refused and stated the surgery was not emergent or life threatening and the risks were not outweighs by the benefit. Surgeon wasn't happy, but patient did have surgery the next day.
Your surgeon sounds ridiculous. Unless there is more to the story, that's just absurd.
As for the labs...well yes, that's on you. I would have made sure to chart that the patient was a difficult stick, that dialysis agreed to draw the labs, and that I sent the labels with the patient. Then it's your responsibility to follow up that it did get done.
I have made many mistakes, but one of my more recent ones really stands out in my mind.
The mistake involved a beta blocker and a tachy surgical patient. Patient was to go for lap chole in the morning, had been on the unit for four hours when my shift started. Day shift never finished his admission and I was slammed with two admissions on my shift back to back. I didn't have time to complete his. He was tachycardic and I called the doctor, patient was febrile, so we thought that was why. HR never normalized even when fever came down. Hmm. Called doc again. Is he on any cardiac meds? I check the MAR...Nope. The doctor figured my rectal temp reading was off. Orders to continue to monitor. I was nervous, because unexplained tachycardia always makes me nervous. Sent patient to pre-op, informed them of the above. Ten minutes later I get a call that the pt had told them he had missed his beta blocker the day before. My face fell. I never verified his home medications. I never even asked! I was so upset with myself. All those interventions and conversations with the doctor, and I had never even thought to ask if he was on any other medications.
BIG lesson learned. Now, even if I am crunched for time, I always verify home meds, even if I don't have time to do the rest of the admission. And if something comes up, I ask my patients again what they take at home. Even if someone else already verified.
Becoming a nurse. What I learned from it was that it was an extension of co-dependency learned in childhood, the whole thing that took me away from my desired path. Fortunately I don't see my age as a limiting factor, and I'm returning to what I always wanted, and that surely has nothing to do with being a punching bag for everyone else.
1. Pharmacy calculates doses based on the most recent weight charted. They do not read notes attached to the height/weight flowsheet that say "weight includes bottom portion of cooling blanket; patient too unstable to turn to remove blanket." (This was per MD order for a neuro patient with ICPs in the 50s that shot up to the 80s with ANY amount of stimulation.)
2. Do not let people make decisions or perform interventions on your patient just because they have more experience than you. If you're not sure, SAY you're not sure, talk it through, and proceed from there.
Suffice it to say that both of these patients ended up being okay, but serious harm could have potentially been done. Everything is a learning experience.
I had been working in a methadone clinic for two years and the clinics executive director was the biggest ******* I've ever met. Basically it was two long years of verbal abuse and I had reached the point when it just became unbearable. I went to the clinic o w nears and told the I had reached the end of my rope. The owners t s liked to me off site and told me they would take care of it. The next day that man spent the first two hours of the shift saying I. A loud voice what going to do to me for reporting him.Then he got a female co worker to tell the owners that I acted inappropriately toward her.The next thing I knew I was given the resign or we fire you option.
I had a crashing patient that needed pressors. We mixed our own. I opened the Pyxis, grabbed the meds. Took the vials to do a double verify with another RN who nodded. Just happened to look at the vials one more time and omg it was a vial of a neuromuscular blockade. Same size and had been placed in our Pyxis under norepinephrine.
i got sick to my stomach and threw up. Called pharm,got the right med stat, and was actually glad I had a nursing student with me to we first hand the experience of a med error.
i still get sweaty when I think about it. The patient wasn't intubated, But very sick. I think I oiled have killed him. Im grateful every day it didn't reach him and I'm still in the habit of verifying the med is what should be in the Pyxis. Which is what I should have been doing in the first place.
Lol I did that on a trauma pt in the ER. Felt stupid, but usually the docs aren't too upset. They'd rather have you actually assessing pts and reporting changes than ignoring symptoms.
This one just happened…I discharged a Pt with a foley but before doing so he asked if he could get a leg bag put on. I checked with my charge nurse to see if I needed an order but she said we do that all the time. So I put on the leg bag and sent him home. Just before end of shift the wife calls a bit frantic saying the foley isn't draining what should she do? Is the tube kinked? No. Is the tube too tight? No. Has she called the MD office. Yes but she only gets the voice mail. So I tell her to come back to the ED and hang up. It was draining just fine when he left so I'm stumped as to what could have happened. A big clot maybe? Then at 2:30 in the morning I realize my mistake. He was ordered to be on bed rest so of course the foley isn't going to drain into a leg bag when he's lying down. Stupid nurse strikes again.
Saline lock flushed with vecuronium. Our unit learned that there shouldn't be stock bottles of vecuronium and heparin flush in the same med fridge.
That's paralyzingly frightening. It's interesting how some medications that look alike (labeled similar, stored in the same way, etc) can have dire consequences if mixed up. It's a lot easier to make these types of mistakes than most of us care to admit.
I was told by my manager that the incident would be reported to administration, and never heard anything else after that.
KRVRN, BSN, RN
1,334 Posts
Saline lock flushed with vecuronium. Our unit learned that there shouldn't be stock bottles of vecuronium and heparin flush in the same med fridge.