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 ICU and Dialysis.
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.

Specializes in ONC, Gyn ONC, BMT, Hospice.

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.

Specializes in IMCU, Oncology.

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!

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