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 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..
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! 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 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 !
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.
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.
I have seen this ordered before. Yes the patient will lose electrolytes, but we can replace those IV, and some surgeons want the stomach to stay mostly empty for a period of time post op.
If I saw this I wouldnt immediately assume it was wrong, but I would clarify with the nurse and check the chart to see that it was ordered to be set up to drainage.
I gave a renal pt 5mg of Ativan IVP, instead of 5mg Valium. I was a new nurse in a new job. The medication machine didn't have individual pt profiles, you just logged in and took out whatever medication you wanted. He was fine after a long nap in the ICU. I learned that anytime you have to access multiple vials to get your dose, stop and think! Yikes. I quit that job and went somewhere that had better protocols (and didn't give med/surg nurses 9 pts on days). I will never forget that feeling.
I mislabeled a vial of blood with the wrong patient label (vancomyocin trough). Fortunately lab notified me and the mistake was corrected!!! I am very vigilant about checking patient labels now!
I hung incompatible IV solutions. Earlier in the shift the patient had NS running, it changed later to a solution with potassium in it. I had forgotten about it and hung a bag of Merrem with the new IV fluids which were incompatible - the patient was busy chatting with me and I was distracted :-(. I returned to the room later to round with the doc, looked up and saw the error! My heart sank, because I realized I hadn't checked compatibility with the new IV fluids. I then looked it up and found that Merrem is incompatible with potassium. Merrem is made less effective in combination with potassium. Thankfully it was not a situation where precipitation could occur. I was really upset with myself but learned a very valuable lesson!
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 
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 
!
MSNMPHPhdNMD
189 Posts
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..