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.
Back when dinosaurs ruled the earth, I worked in an adult ICU. My patient had a swan- ganz as his only access, and had dopamine running in the distal port. His pressures and CO were getting better, and I weaned it as far down as I could. Called the doc and got an order to D/C. Stopped the dopamine and flushed the whole line with saline ---- rapidly! The guy's heart rate and BP skyrocketed, and he said "Yeah, so I'm feeling a little shaky....." It lasted a couple minutes - the longest 'couple minutes' of my whole life!
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!
To be clear I gave the 20 meq of k over about 1/2 hour and was surprised that nothing happened. Yes you are correct the pt would not have pvc's I was wrong about that. I was surprised that their heart did not stop/ they did not have rhythm changes from getting kcl too fast. I always make an RN go and double check my drips now and if they don't really look at it I get someone else. It's easy to make a mistake when things are moving fast.
Even those who are not nurses or in the medical profession can at least be advocates to their own healthcare. At the very very least, check the prescriptions you receive from the pharmacy against the description that comes with the information packet you get with it. If you have never taken it before, speak with the pharmacist when they ask if you would like to. And if you are chronically ill and know your regimen, speak up about something that is not being done as it should be. Sometimes patients know more about their bodies than health professionals do.
I accidentally attached Pitocin instead of LR directly to the hub of a triple codon and opened it wide; the lines were clearly labeled, I was just chatting with mom and not paying attention. The patient may have gotten, at max, 2 cc's before I caught the mistake. The patient had a 10 minute tetanic contraction. I put mom on a mask and stayed at bedside. Thankfully the baby's heart rate stayed stable and mom was ok. I explained exactly what happened and mom revealed she is a RN in a neighboring city. She and I ended up turning it into a learning opportunity. She was amazing but I still have not recovered! The midwife, unit director, and charge nurse were all amazing actually. My mistake caused a change in line label sizes and colors to draw more attention to high risk drugs.
Fantastic to see a precarious situation turn into a learning experience for EVERYONE. I am glad it lead to changes to further protect the patients from mistakes and the staff from making them! Sorry it happened but great to hear the positive changes that proceeded it!
I just found out that we are not allowed to start an IV at any of our clinical sites (I think because of insurance reasons). We do have to know the mechanisms of how to do it, but the only practice we get is in lab next week on a fake arm that bleeds. I think it's a little crazy that we won't be able to start on IV on a real person until we are licensed RNs.
Practice on each other! That is what they do at the school where I work. They practice their blood draws on each other (and anyone they can sucker into it!) I always volunteer because I figure it is just a simple stick, usually butterfly, which they miss half of the time anyway. Newbies, gotta love em!
I learned to speak up if I don't feel the assignment is safe. I got into a situation where I was new and I was scared of the assignment at report time. But I thought, I can handle this, it's a good learning experience right? Wrong. I made a mistake that did not harm anyone long-term but it was because I was overwhelmed and feeling anxious and rushing. There is a fine line between being out of my comfort zone but I can make it fly, and not being safe because I can't handle all the tasks and have time to slow down, think about what I'm doing, and keep a good eye on the patient to watch for changes. I am now very free to tell my charge nurse my feelings and ask for help. Last night was one of those nights that at report time I knew it was going to be tough as I had two very touchy patients with lots and lots of tasks to complete that it was impossible. I spoke up and another nurse was assigned to take over one of my patients for part of the shift-- she had an open bed still. Later on things had settled down and I took the patient back into my care while she took the new admit.
Is it just me, or does it appear that you can give just about any dose of Coumadin, and the INRs go all over the place, almost as though they have a life of their own? A crapshoot, even? It must the most unpredictable med out there.
I learned to speak up if I don't feel the assignment is safe. I got into a situation where I was new and I was scared of the assignment at report time. But I thought I can handle this, it's a good learning experience right? Wrong. I made a mistake that did not harm anyone long-term but it was because I was overwhelmed and feeling anxious and rushing. There is a fine line between being out of my comfort zone but I can make it fly, and not being safe because I can't handle all the tasks and have time to slow down, think about what I'm doing, and keep a good eye on the patient to watch for changes. I am now very free to tell my charge nurse my feelings and ask for help. Last night was one of those nights that at report time I knew it was going to be tough as I had two very touchy patients with lots and lots of tasks to complete that it was impossible. I spoke up and another nurse was assigned to take over one of my patients for part of the shift-- she had an open bed still. Later on things had settled down and I took the patient back into my care while she took the new admit.[/quote']
^Learning this as well...again, as a new grad (from being an well-rounded LPN)
Had a similar "come to Jesus" meeting with me orientation coordinator. It is a HUGE learning curve, this CC machine, and I knew that coming in and was vocal about that. Guess I wasn't vocal enough, or my communication on my part was more to the different culture of the unit and hospital, in addition of what you are experiencing above. This is one of the few places I worked where it is a positive work environment-SO NOT used to that! Any-who...I spoke up well enough for her to decide "I haven't given up on you yet." Well I don't give up on myself lol..but I'm working at it...from here on out, I'm MAKING it CLEAR... for the sake of safety,my pts and my SANITY!! We will get there!
Biggest mistake I ever made as a new nurse is with IV fluids and I saw nurses that started behind me, make this mistake over and over again. It could have been fatal, but luckily the odds were with me that night.
They say you should always do hourly checks of your IV rates (to make sure the same rate is on the pump), which I ALWAYS did.
However, when fluids are changed out by shift, what I never thought to do, is follow the line from the bag through the pump slot to make sure the IV that I thought was running at 25/ml an hour was the IV I WANTED to run at 25/ml an hour.
I accidently transposed two fluids when I changed the bags and lines out and didn't discover this until much later in the shift.
I can tell you this..I never made that mistake again.
I left a tourniquet on someone's forearm for about...30-45 minutes. Yup! It was the end of a really lousy day and I needed to grab some blood from a LOL before report. Got the tubes I needed and gave report to the night nurse and went home. The next morning I came back and the nurse said, "just a heads up someone left a tourniquet on her arm, luckily it wasn't tied tightly and it didn't occlude blood flow, just be careful." It still haunts me to this day. After drawing blood or starting an IV I've been known to check and recheck 3-4 times. It could have been so much worse...
I inserted an NG tube and checked for proper placement, both by auscultation and pH. Both confirmed it was in the stomach. The doc ordered the NG to be hooked to suction, so immediately after checking placement I hooked it to the suction. I completely forgot that before anything happens with the NG tube it has to be confirmed by x-ray for proper placement! Luckily someone else caught it after it had only been hooked to suction for about 30 min. I felt so stupid, but was relieved when the x-ray confirmed it was in the stomach. I'll never make that mistake again!
meanmaryjean, DNP, RN
7,899 Posts
Back when dinosaurs ruled the earth, I worked in an adult ICU. My patient had a swan- ganz as his only access, and had dopamine running in the distal port. His pressures and CO were getting better, and I weaned it as far down as I could. Called the doc and got an order to D/C. Stopped the dopamine and flushed the whole line with saline ---- rapidly!
The guy's heart rate and BP skyrocketed, and he said "Yeah, so I'm feeling a little shaky....." It lasted a couple minutes - the longest 'couple minutes' of my whole life!