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.
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.
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
Not correctly assessing life threatening symptoms. Go with your gut. It's the right thought, once you start attributing symptoms as lesser signs it could be fatal. If the first thing in your mind says "oooh he doesn't look good" or "oooh he looks like crap" go with it. Get help.
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
Your preceptor should have been assisting you and making sure you were doing it correctly.
What an incredibly poignant post, and what courage to talk about it. I can easily imagine myself in the exact same situation (I work in a MICU and wish withdrawal of care for at least 50% of my patients, witnessing their suffering and aching decline). Thank you for sharing your experience and making me feel a little less alone.
I am new to surgical nursing and a patient who was post op came from ICU to the previous shift nurse with a foley bag connected to a PEG tube and draining. Both I and the previous shift nurse thought it was strange, but he came from ICU like that, and during my shift the surgery team came and rounded on him and saw it. Of course the patient lost electrolytes. I have learned always to question or ask when you think something is strange.
The scariest was not one I did but one that I caught. I was taking report on a patient who was 2 hours into CABG recovery. The off going nurse reported that she had just hung Hespan for hypotension. I noticed the BP was not coming up and most of the bag had gone in. With horror I realized that what was hanging was not Hespan but was a bag of Heparin. About 300ml had gone in. The patient was fine after Protamine. Yikes!!
I was a nurse's aide in college at a pretty poorly-run nursing home. A woman I was assigned to had a walker next to her bed and asked me to grab it for her so she could make her way over to the bathroom. She seemed alert and oriented and very steady with the walker, so I didn't question it and walked next to her on the way to the restroom. I stepped away for a second to open the door and down she went. Thank god no fracture.
This JUST recently happened to me and I'm beating myself up on it. It was a car in surgery where two different surgeons were working. When the first surgeon was done, the nurse that was giving me a break paged the other surgeon. I come back from my break and was given report. I waited about 20 minutes before calling into the other surgeons' OTHER room to ask a question. It sounded like they were busy so I got my question answered and hung up. Next thing I know, it's an hour and a half later. The surgeon is still NOT in this room and his patient is still under anesthesia. I finally go to the other room to see what is going on and the MD said he never got paged and he was just hanging out in this room and not ours bc we didn't call. Turns out, when the operator called to tell him to come to my or room, he cut her off and thought he was needed in his other room. A five hour procedure ended up being 7 because I didn't call in the room and ask if he was ready yet bc we were waiting on him. I felt so bad! Even the doc was telling me that he was at fault too. Today, I got called to my CC and he asked what happened and I told him what happened and it was my fault. I'm freaking out! Like, is this fireable? The patient did great under anesthesia and nothing bad happened but omg I just feel so bad still!
(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
Nurse3000
60 Posts
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.