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.
I administered Rocephin to a patient with gonorrhea, and I had not twisted the needle tightly enough on the syringe. Thus , medicine leaked out when I administered it. The doctor said the patient would have to abstain from sex & return for re-testing in 4 weeks as a consequence. I flagged her chart so I could make sure she returned. I called & called, but she never returned. If there was a slight bump in gonorrhea rates in my community during that time frame, you're welcome!
1. Giving a different concentration of a low-molecular weight heparin to a pt; right med, wrong dose...was on orientation for a week, new preceptor...first incident report as a nurse. Told the pt immediately, was super cool about it, doc was too, pt survived.
2. Gave pt med AFTER another nurse gave the dose of medicine. Assignment was changed. That nurse was very ineffective at communication, teamwork, and was known to be unsafe...medical debris easily accessible to the children...literally rushing around to make sure kids did not have access to being injured, infusing incorrect feeds to the wrong pts. Job has ONLY paper charting, no high tech fail safes. Instituted a LOT of policies because of a lot of issues with this nurse. FINALLY got fired after her almost 4 years of "service" to our pediatric facility. Still makes me hyper vigilant to check and trust my gut judgement, and literally harass people and continue to check the assignment throughout the day for any "surprises"... :-/
A LOT of near misses in between and after the last incident, even in declining or emergency situations. I just try to remain as safe as possible...
Mine happened just last night! Hence the reason I searched "mistakes" on here as soon as I came home, crying.
These happened with the same patient:
1. Patient had order for lorazepam 1-2 mg IV for seizures. I read the order as IM and gave as such. Realized that this morning, and also realized that I wouldn't have been able to give it IV anyway, because I am not a critical care RN. Called the MD on-call who was unphased and said "Oh, okay! Whatever" haha.
2. Also this morning, realized my patient's foley cath output was ohhhh about 100mL overnight, and I was so preoccupied with the 1 million other tubes coming out of her, I didn't even realize.
I actually want to quit and hide in a hole. 1st year of nursing is sucking.
I infused an entire unit of platelets on a little girl in under an hour. One of the clamps that should have been closed (the clamp running from the bag to the syringe) wasn't fully closed. So while the platelets were running from the syringe pump they were also running by gravity. Luckily nothing happened.
I had a resident on 3 anti seizure meds. One med, I didn't know it wasnt for pain but for seizures(it was in narc box). Brand new nurse, overloaded with residents, decided to give his meds last. Shamefully I hadn't looked up the reason for the med. He got it, but like an hour late! I can't believe I didn't look it up in the drug book. I felt so bad when I finally did look it up.
Mine happened just last night! Hence the reason I searched "mistakes" on here as soon as I came home, crying.
These happened with the same patient:
1. Patient had order for lorazepam 1-2 mg IV for seizures. I read the order as IM and gave as such. Realized that this morning, and also realized that I wouldn't have been able to give it IV anyway, because I am not a critical care RN. Called the MD on-call who was unphased and said "Oh, okay! Whatever" haha.
2. Also this morning, realized my patient's foley cath output was ohhhh about 100mL overnight, and I was so preoccupied with the 1 million other tubes coming out of her, I didn't even realize.
I actually want to quit and hide in a hole. 1st year of nursing is sucking.
You can't give lorazepam IVP? We give it all the time on MedSurg.
You can't give lorazepam IVP? We give it all the time on MedSurg.
That's what I was thinking. I am surprised by these things I read on here and wonder what caused these policies to be placed. Probably things that belong in this thread.
~ No One Can Make You Feel Inferior Without Your Consent -Eleanor Roosevelt ~
Specializes in Telemetry, Oncology, Progressive Care.
You can't give lorazepam IVP? We give it all the time on MedSurg.
I've worked at a couple of facilities and was always able to give lorazepam ivp. Never given it IM. Haldol is another story. I worked at a facility where only ICU nurses could give haldol ivp d/t prolongation of QT if administered too quickly. We could give IVPB.
Yeah it sucks when you make a medication error. I've made a couple in my years. I was still a new nurse on orientation and heplocked a dialysis catheter on a pt who was HIT +. I let the nephrologist know. They wondered why I called about that. Likely none of it got to them systemically.
Just a few months ago I had 5 patients and they were all on some sort of drip (I was the only nurse with patients on drips that day and I got them all). I started a bumex drip and I am not as familiar with that as other medications. I programmed the pump incorrectly. I believe I was supposed to have it going at 3 ml/hr and had it going for 3 mg/hr (don't quote me on those numbers). I was used to lasix gtt's which are 1 mg = 1 mL. The nurse on the next shift didn't catch it either and the nurse on the following shift caught it 6 hours into her shift. I apologized to the nephrologist the next day and he told me not to worry about it. The particular nurse who assigned this load to me does a horrible job of making assignments. I've complained and my manager blows me off about it. My educator talked to me about the mistake. I told her it was not a good day for me on the unit and they shouldn't assign all the drips to 1 nurse when there are 7 nurses on the unit. That wasn't an acceptable excuse.
Unfortunately mistakes happen. We're only human! We try our best and would never intentionally harm someone.
Patient was supposed to get 3 units of Novolog but ended up getting 7 units because my CNA mixed up the blood sugars and told me the wrong one. Patient was okay and actually their sugar ended up being even higher the second time around. Moral of the story: now I make sure that glucometer gets docked so I can actually see the blood sugar results upload into the computer and into each patient's individual chart.
This was a mistake I made somewhat recently. MD ordered a unit of blood to be given. Apparently this order was put in at 12:30 and was missed by the dayshift nurse AND me. Patient was to go for an amputation the next morning and the surgeon calls me in the AM and asks,
"Did Doctor X order any blood?"
*frantically searching through the patient's chart and looking at all of the patient's active orders* "No, sir, I do not see an order here."
"Oh, okay then. I will call Doctor X. Thank you."
A few minutes later one of the CNAs (and I don't know why she was the one to tell me or why she spoke to the doctor) came up to me and said, "umm just so you know, the patient's surgery got cancelled and the doctor called and was ****** and he wants you to call him back NOW." I just wanted to cry, crawl under a rock and be left alone. I called the surgeon, and surprisingly I didn't get chewed out, they just told me the surgery will be post-poned until tomorrow and the patient will just get the unit of blood during their scheduled HD today.
I spoke to the dayshift charge and told them what happened, they said "well whoever it was before you should have been the one to administer the blood" but I told them that since it wasn't completed on their shift, it falls on my shift and it became my responsibility.
So what happened? The MD ordered 1 unit to be transfused but wrote that in the patient's hemodialysis orders. We have computer charting at work and we have been told by management not to start the HD orders; only the dialysis RN is supposed to do that. So, naturally, I ignore them. I just see "Hemodialysis" in the planned state. When I looked at the plan, there was the order: "transfuse 1 unit of PRBCs." I could not have initiated that order without initiating the entire HD plan. Of course, I didn't see this until after I had learned the surgery was cancelled and that the MD indeed ordered a transfusion.
Regardless, I told the dayshift charge I would take full responsibility for whatever happened...I told the patient and they were very upset with me, as they should have been. Anyway, the patient went for surgery the following day and everything turned out to be A-OK. Thank goodness.
So I feel like mine are so much worse than these! But here goes: I had a post-op CABG pt and have 20 meq of kcl via the central line. I got distracted and programmed the iv pump as an antibiotic and have the kcl at 100 ml/ hr when it was supposed to be given at 50ml/ hr. I realized it when the bag was almost empty. I did ask another nurse to double check it but they apparently missed it too. The pt was fine however. Not even a PVC worth if ectopy!
The next one is a little more embarrassing. I had a pt that had a sternal wound infection being irrigated. I was trying to change the dressing around the tiny irrigation catheter and accidentally slit the catheter. The surgeon was ****** and yelled at me in front of everyone. The pt had to go back to the OR and have the catheter replaced. I felt like such a loser that day.
So I feel like mine are so much worse than these! But here goes: I had a post-op CABG pt and have 20 meq of kcl via the central line. I got distracted and programmed the iv pump as an antibiotic and have the kcl at 100 ml/ hr when it was supposed to be given at 50ml/ hr. I realized it when the bag was almost empty. I did ask another nurse to double check it but they apparently missed it too. The pt was fine however. Not even a PVC worth if ectopy!
The next one is a little more embarrassing. I had a pt that had a sternal wound infection being irrigated. I was trying to change the dressing around the tiny irrigation catheter and accidentally slit the catheter. The surgeon was ****** and yelled at me in front of everyone. The pt had to go back to the OR and have the catheter replaced. I felt like such a loser that day.
Agreed with the previous post, a common EKG change with hyperkalemia is peaked t waves. Then you'll see a widening of the PR interval and eventually you'll lose the P wave all together with a widening QRS complex. This is all with a K greater than 6 at least. I'm assuming if you were giving KCl the K was less than 4 and the patient had working kidneys. Plus, where I work we run 20mEqs in 100mL over an hour routinely. The only time we run it slower is if the patient doesn't have a central line. Basically what I'm trying to say is don't beat yourself up about that mistake!
I have been really lucky. Once I was working pool at a new hospital and I mixed up bed A and B and gave the one patient thiamine and lisinopril that were meant for the other. I got the feeling something was wrong, so I double checked and discovered my error. My heart was beating really fast. We checked the guy's BP all noc, no problem.
Another time, I was in charge and had a full load of patients. I was drawing Dig for a patient in A-fib and a resident kept talking to me about other patients while I was doing it. The dose was 0.125 and I drew up the whole vial of 0.5, but I realized it just before I gave it to her, so no biggie, but my heart was beating fast again. I learned not to let other people disrupt me so much while I was doing meds.
As a new grad, I made some typical mistakes. I let someone talk me into doing a double at a private duty quad with a vent. I checked her foley and it had the right amount of urine for one shift, but not 2 shifts. Her foley tubing was bent and she had spinal dysreflexia because of it. Luckily, I caught it when she just had the "sweats" and no other sx. I learned not to let others push me into things I know I can't do.
Another new grad mistake I made was writing down a verbal order from another nurse. It was wrong, and I ended up being written up for it. I did write it. I learned never to write orders for another person.
Another new grad mistake I made was allowing a family member yap at me while I was trying to draw blood from a CVL on an HIV pos patient. I ended up sticking my finger with a 16 g needle from the patient and it was quite deep and drew my blood (this was before needleless systems were commonplace). That was a nerve-wracking first year, waiting for all those HIV, Hep b and C tests! I learned to always ask visitors to step out while I do any procedure, even if the patient says it's okay.
I just wanted to cry, crawl under a rock and be left alone. I called the surgeon, and surprisingly I didn't get chewed out, they just told me the surgery will be post-poned until tomorrow and the patient will just get the unit of blood during their scheduled HD today.
mariebailey, MSN, RN
948 Posts
I administered Rocephin to a patient with gonorrhea, and I had not twisted the needle tightly enough on the syringe. Thus , medicine leaked out when I administered it. The doctor said the patient would have to abstain from sex & return for re-testing in 4 weeks as a consequence. I flagged her chart so I could make sure she returned. I called & called, but she never returned. If there was a slight bump in gonorrhea rates in my community during that time frame, you're welcome!