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 CPAN.

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.

Specializes in Emergency Nursing, Pediatrics.
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!

Specializes in Hospice,LTC,Pacu,Regulatory,Operating room.

lord. i put an IV in connected the bag and it was flowing. I forgot to pull out the damn needle. It did not infiltrate or injure the patient and all her fluid flowed. I did not notice until i dc'd the IV. Needless to say i never did this again..

Specializes in Retired NICU.

So many I could choose from in my 39+ years. Can't say which is my "worst" error, I keep remembering different ones as I read through everyone's posts. I'm in NICU, so everything is on small scale. Most of these memories are from decades ago. I must say that I do appreciate that technology does decrease medication errors, although it may cause other issues! :unsure: Once I ran IV lipids in over 20 minutes instead of 20 hours. Once when I was just back to work, newly postpartum, with that brain mush mode going on, I showed a mom how to give her baby oral Reglan (thankfully I wasn't instructing her on how to draw up the dose!), and blissfully drew up 10 x the dose and gave to to the baby, and didn't even realize what I'd done until a day or two later! I assisted the doctor with a UVC insertion, then immediately accidentally pulled it out with the bell of my stethoscope that was wrapped around my neck :eek: Once I just couldn't get an IV restarted on my baby, my coworkers couldn't either, we called the charge nurse to start it, she was an IV goddess, she got it in, the baby was in a very old fashioned isolette, and the IV was in the scalp, I didn't pay good attention to the tubing when putting the baby back to bed and managed to accidentally pull on the tubing with the isolette door and rip out the IV, of course it was change of shift and the end of my shift :cry:!

Specializes in Reproductive & Public Health.
lord. i put an IV in connected the bag and it was flowing. I forgot to pull out the damn needle. It did not infiltrate or injure the patient and all her fluid flowed. I did not notice until i dc'd the IV. Needless to say i never did this again..

I once inserted an IV cath facing distally :/ And the patient's husband was a medic, watching me do this. I cannot even believe it, to this day.

My very first error as a nurse was while I was working at a boarding school for teenagers with mental health needs. I gave a patient her morning vyvanse , instead of her night time vistaril. Ahhhhhhh.

I once reported a P/CR ratio of 1.2 (or something like that), instead of 0.12. I was confused when the resident showed up 3 seconds later in a panic.

I once accidently left a patient sitting up in their room after taking them back from the cafeteria without hooking them back up to the wall oxygen and taking off them off the portable. Luckily respiratory caught it, but it had been at least an hour. I felt so horrible. Family had come in like they did everyday and didn't catch it either, but it made me feel horrible when respiratory came up and told me what happened. I'm glad somebody caught my mistake.

Moral of the story: Don't get so involved multi tasking trying to take care of all your patients that you skip the details and neglect the patient that you're taking care of in the moment. Don't just go through the motions! Always watch what you're doing, even if the unit is on fire. Lesson learned.

I accidentally mixed up two patients medications. It was in LTC and the gentlemen looked extremely similar with the same last name. Luckily nothing bad happened but I lost a lot of sleep over that one.

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