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

Nurses General Nursing

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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.

Specializes in NICU.

I'm leaving out most of the details but...

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.

Specializes in geriatric/long term care.

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.

Specializes in Emergency, Trauma, Critical Care.

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.

Specializes in Emergency, Trauma, Critical Care.

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.

Specializes in Adult M/S.

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.

Specializes in Aged, Palliative Care, Oncology.

lol i had to share this with mum. im glad u ok. but jeez.... he sounds scary

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.

Specializes in Aged, Palliative Care, Oncology.

UM, One of th reasons why i have googled/sought out this post is because I made my first mistake which required getting the whole team involved. Everyone was very supportive, including the patient! Due to new & covuluted chart, I missed 3 doses of insulin for a pt. I checked her Blood sugar but boy did i overlook that insulin order.here in some states the order is on a seperate chart to the other med chart, which doctors and nurses alike think is a crappy move as its more confusing.

The report was done, the pts bsl was ok, considering she didnt have insulin, 13?.mmolL and even though she is on the ball didnt mention anything to me, which is not her responsibility to, but we were suprised she didnt.

She is ok, im still recovering and i have def. learned to be much more attentive to smaller details. p.s. its my first week as RN.

As a new nurse I made a really stupid mistake that I never made working as a cca or a nursing student. My patient was really sick

and needed to be catheterized and another nurse was with me and was going to grab a catheter tray and Foley for me. Well the patient

was up in the bed with the side rails down and I turned to grab something from the other side of the room and left the side of the bed not even thinking...nothing happened but I felt like the biggest idiot for the rest of the day. I was only away from the bed for five seconds

but that is all it could of taken for something terrible to happen. I was just so focused on all of the patients co-existing illnesses I made a

mistake about the most basic part of patient care; safety.

Specializes in Peds, Neuro, Orthopedics.

I've learned that a med error in one hospital isn't a med error in another hospital. For example, I was rushed one night and didn't dilute a particular medication. I was worried about what would happen, because I had no idea why I even needed to dilute that med. At hospital #2, we don't dilute it, so I guess nothing bad happens. Weird.

Gave a diabetic patient a bolus of D5 instead of NS once...They were ok but a bit hyperglycemic for a while. I felt like crap though. Moral of the story...no one is perfect

I feel absolutely ridiculous from today... so i googled mistakes in nursing to relate to SOMEONE! This mistake actually isn't too bad, im in my preceptorship though - my preceptor isn't fond of me, and lets just say home care is not my forte right now...

I had to do a (unplanned) catheter change on a client. I checked with the client to make sure they had all the supplies, which they did. So me and my preceptor drove out... as I finished setting up my sterile field... i realize (well actually my preceptor realizes) I dont have a fricken 10cc syringe to deflate the balloon!!! AHH! and of course the client doesn't have any left by other nurses in previous visits...

Luckily my preceptor had the idea to just use another syringe from another catheter tray... and we would just bring more the following visit... does it end there? absolutely not!! I get back to the office and check voicemails... and the client (such a lovely patient person) called to say the catheter bag was connected upside down... so no urine was draining at all!! (I need to add that i got only a few drops of urine back during the insertion, as the previous bag was quite full). However, I didn't even think to check that the numbers were lined up correctly (top to bottom) because I was so flustered about the syringe; and the top and bottom caps were identical :( (Still, it was my mistake - no excuses, i should have paid more attention). Luckily the client was able to reattach the bag, and it drained fine... and I would have been able to go out to correct the mistake within the hour.... i just felt like it was a wave that would not stop crashing... it was awful. I felt like a moron. Hopefully I pass my preceptorship! haha

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