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 made one during my preceptorship. It was not uncommon on this floor for nurses to really help each other out - give so and so some insulin for me, draw up some insulin for me, can you change a rate on X, etc. Well. I told my preceptor what the patient's CBG was and she volunteered to go draw up some insulin. Key word: some. I think she had said at some point that she had drawn up 10 units of insulin, but I was thinking about something else and it just went in one ear and out the other. The patient only needed 2 units, but it was pretty common on the floor for a helping nurse to draw up maybe 10 or so units so the person at the bedside who was tied up could waste the rest in the sink and then give an appropriate amount. In my absent-mindedness I did not look at the syringe other than to hold it, assuming my preceptor had checked the MAR and drawn up the correct amount, and did not waste any of the insulin in the sink but instead gave the full 10 units to the patient.
I got that feeling that something wasn't quite right immediately after I gave it, asked my preceptor how many units she'd drawn up, and got that funny feeling that ran through my whole chest and felt like someone was applying an ice pack to my sternum. Fortunately, the guy was on continuous enteral feedings and I checked the CBG pretty often and his never dropped below 100. In fact, that was one of the first times his blood sugar had been under 200, so maybe the sliding scale needed to be adjusted, or the feed formula needed to be adjusted, or something. Either way, he was fine, and I learned that if anyone else hands me anything that I've asked them to bring, should the occasion arise, that I should NOT trust that they got it right and should definitely check the med again myself before giving it. I will remember that awful ice cold feeling forever, and I hope I never feel it again!
Not a SERIOUS nursing mistake, but def embarassing...
Dont ever assume somebody is the father or son or whatever. ALWAYS ask how they are related. Some of my most embarassing moments is when I say something about "your dad" and the patient says,"um, that's my boyfriend"... or whatever.
SOOOOOO want to put my foot in my mouth!
HAHAHAHAHA I've done that several times myself! Talk about hopping out of the room cause I sure stuck my foot in my mouth!!
i worked on a locked psych dept. and quickly learned three lessons:
1. never wear a necklace, earrings, etc. to work.
2. never turn your back on a patient, mo matter how normal s/he appears.
3. never try to have a conversation with a 400#+ h*ll's angel pt. alone. i am 5'4" and weighed
about 110#, and was absolutely no match at all. he grabbed me and suddenly i was airborne.
he yelled "make a wish, b*tch! he had grabbed me by my right shoulder and left hip. fortunately
three large male aides heard him, then heard me scream.
I also work on an acute care locked psych unit and recently made a mistake when I should have known better. I had 2 male patients get into a physical altercation. One was psychotic and paranoid but worked well with me; the other had anger management issues but was actually in the process of being discharged.
Without thinking I jumped in to break it up. (At 5'3 and 100 lbs, what in the world made me think I could stop 2 angry men?) Got caught in the middle and a punch intended for the other guy hit me in the face instead.
Their doc was on the unit and got there in time to see me thrown to the floor. He quickly diffused the situation. Expedited the discharge of the one who hit me, and increased the medication of the other.
Lesson learned: Don't get parental and think because patients know and respect you they'll listen when you jump in and yell "stop"!
Like others I'm not saying but I do learn from them.
A more harmless....humorous one.....I was walking with my new patient, holding her chart, bringing her back to her room. I was looking at her "face sheet" which has the patient's name, address, phone, and insurance coding information, to remind myself what she was having surgery for.
She was getting a breast biopsy for fibrocystic breast disease. The clerk had mistakenly entered cystic fibrosis...I blurted out..."You have cystic fibrosis!" She gasped....."I do!" I immediately realized the, my, mistake and explained the mix up, ha ha...it took a few minutes to convince her. I'm sure for a few seconds she thought maybe she had it, her doctor just hadn't told her yet? (I also had the clerk change the coding.)
I gave a patient a calcium pill ( huge horse pill) to swallow whole. He immediately started to gag. I took the pill outbid his mouth and gave him his water. I noticed then that he was on thickend liquids and I should have crushed the pills. I thank God for the rest of the shift that he didn't die over this. I still think about it to this very day.
I once gave insulin sub q instead of ivp. I was rushing and didn't thoroughly check the 5 r's .
One time I pushed reglan too fast.... And we all know what that does.....
I'm just finishing my preceptor, the other day I was on an out pt/urgent care department returned from my break and the nurse I was working with pointed to the morphine and gravol she had already pulled out and said pt X needed it. I confirmed the order, did the calculations correct, got it double checked by the nurse (Im paranoid about giving the wrong amount so I always do the math), confirmed the patients ID, and even confirmed that they could have morphine, another nurse observed me give the IM. Then I saw the allergy bracelet under their sweater, there was allergic to codeine. I seriously thought I was going to vomit, I immediately got a hx on their reaction (swelling), and told the supervising RN, who said we would observe the pt, and explained that doctors frequently prescribe morphine to patents with codeine allergies. I checked on the pt multiple times, did VS, and thankfully they had no reaction, even called the hospital 3 hours after I got home to confirm the pt was okay. I feel like a failure and I keep analyzing what I did and seeing all the possible times I could have prevented this mistake. I'm super ashamed. Called my supervisor from the university crying. She was a great support, told me I handled it correctly and that I'm accountable. I keep trying to think that everyone makes mistakes, and that we should not be judged based on the mistakes we make but on how we handle those mistakes... but I cant help but think maybe I should have considered another career choice...
I am a new nurse. I've only been at my hospital for 8 months. This is great reading these. Your experiences just may protect me from repeating them. Thanks for sharing! Mine are both fall situations.
The first one was when I was still in clinicals. One of my fellow students asked me to cover for her while she took a break. I just said sure and got a short report but neglected to find out their assist status... ummm, probably one of the most important things to know. I answered one Pt's call light (a hip replacement) who asked if he could get up to go to the bathroom, "SURE!" I say with an enthusiastic smile. He gets there fine and is standing there with a walker blocking his way to the toilet and says, "maybe you should just hand me that urinal" I stepped away from his side two measly steps to grab his urinal, he went down, and he went down hard. Come to find out his block was just recently removed and he had not stood up yet. I should have had two people there with hands on him at all times. He thankfully had no injuries. I was expecting a dislocation and return to surgery.
You would think I would learn... nope. Just last week I had admitted a woman who was ambulating independently with no signs of weakness. She was on the toilet and said she felt dizzy. What I should have done, called someone to come in and help get her down to the floor. I should have been Pt focused. Instead I was data focused and felt I should get her blood pressure. I suppose that wouldn't have been to terrible if I had someone there to keep a hand on her while I did but no. I grabbed the blood pressure machine and took her blood pressure. As I was writing my data on a paper towel she went down, face first, onto the floor. I thought for sure she had broken her nose or something but she never developed even the tiniest of bruises. God was with me on that one.
I have got another one for you. I was teaching a patient how to use an inhaler. I said quote "you have to take a deep breath in order to get the medicine down into your lungs to open up your areolas" . It wasn't until I walked out of the room that I realized I mean alveoli. hmm yeah very embarrasing. by the way it was a male patient :)
Didn't question the doctor when she ordered a medication with a similar name instead of the intended one. I was new and shy at the time, and figured that it was an usage I wasn't aware of. Nowadays I'd just ask what the heck she was ordering that for. Luckily, no harm done, and I learned that docs really do make mistakes that we have to catch.
Gave the wrong patient the meds. No good reason - it was the end of my 4th 12 hour shift in a row, and I got distracted in between the med cart and the table and gave it to the previous person on my list instead of the correct person. Again, no harm - the medication was the same med, same dosage that she was supposed to receive at HS, so we just held the HS medication. I stopped doing 4 shifts in a row and double-check myself if I get distracted between med cart and patient (this is LTC and we have no wristbands to check).
Discussions like this are so helpful for us nurses - it just takes one moment of carelessness (or naivete) to make a mistake ... and once we do, hopefully we'll learn from that and move on. I've been a nurse for a little over 2 years, working on a tele unit for 15 months and now working on a medicine unit at a new hospital. In just the last couple of weeks during orientation I've made so many mistakes! I think when we all own up to our mistakes with honesty, knowing we were doing our best, we can move forward and not be hindered by shame. It's easy to feel so down on yourself and worried but those feelings only make things worse, in my opinion. Ok, here are mine from just the last couple of weeks...(yikes, there are a lot! learn from me!)
1. Believing a 350+ lb paraplegic patient that he could transfer himself from the bed to the wheelchair using the overhead trapeze and standby assist...3 of us nurses at the bedside and the patient almost fell to the floor during this transfer! I urged him that we should use the lift equipment but he INSISTED that that was unnecessary, as he was going home and very anxious to get out of the hospital. We are taught to listen to our patients but in this case I should have listened to my GUT, and NOT the patient. Not only could he have injured himself further - all 3 of us nurses assisting him in the transfer could have severely injured ourselves in the process with that much dead weight involved. ALWAYS use lift equipment or be 100% confident in the people you are trusting to move your patient (such as a lift team or several muscular men)! And don't always abide by what your patients think is best for them - use your judgement and act for their safety first and foremost.
2. When drawing a lab from a central line, double check and ***make sure**** nothing is in the line upstream that could alter the test result (whether an electrolyte or drug level, etc.). I drew from a central line a potassium level. I looked upstream and saw that the potassium piggyback bag was empty and had been done for quite some time with the maintenance fluids (NS) below it running into the line. I thought to myself, "The potassium's done, so I don't need to disconnect." I drew from another port on the central line while the supposed maintenance fluids were still running, and lo and behold, the K result was critically high at over 10.0. There must have been some K+ still in the primary tubing which threw off the result. Better to be safe than sorry - ALWAYS just disconnect or put EVERYTHING on pause while drawing blood from a central line.
3. I was under the assumption that pharmacy pretty thoroughly reviews allergies before putting any MD drug orders through to the pyxis. I should never make this assumption. I had a patient with an allergy to iron and was given a multivitamin (new order). Thankfully she questioned what the pill was and had the insight to think it probably had iron in it, so she didn't take it. This particular lady had about 25 drug allergies so it's not surprising that she's very aware but I should have caught that too...
4. Don't EVER put a controlled substance into a general med stocking area. I pulled out ~10 meds for a patient, including a fent patch. Another nurse had already given (a different) fent patch that morning to treat her pain and my pt was unable to swallow so I ended up not giving her any of the meds I'd pulled from the pyxis. I'd completely forgotten that one of those was a controlled substance (the patch) and put ALL of the meds I'd pulled for her into a plastic bag and into her little cubby inside the pyxis tower for return to pharmacy. Pharmacy came back to our unit and asked the manager who put the fent patch back into the pyxis and of course I owned up to the mistake. Always return all of a patient's meds individually into their pyxis cubbies (not only are they charged every time you pull the med from the pyxis) but you could make the same mistake I did and put a narcotic patch in an open area inside the pyxis machine. Though unlikely, another RN could have opened the pyxis tower, then opened the plastic bag, and taken the fent patch...and my license would've been on the line if that fent patch was never recovered.
5. Never forget to tell the next shift about timed lab draws. I had a pt on a lidocaine drip with lidocaine levels to be drawn Q8 hours. She of course had a central line so these draws were to be done by the nurse and not the lab. I failed to mention this while giving report to the next shift. Even though she would have seen the order for this on the pt's profile, it could have easily been overlooked and our pt may have been getting either sub-therapeutic or toxic levels of the drug without the Q8H draws to monitor.
6. Never hang a piggy back med onto a pole and plan on "coming back" to it after you administer oral meds. I did this yesterday and the pt noticed that it wasn't connected to her and just hanging on the pole. Not only was I mortified, the pt didn't get their medicine on time. If you have a piggy back med, hook it up and program it ***right away*** before trying to do something else and you forget about it!
7. Always wear gloves when doing ANYTHING with a central line. Even if you wash your hands thoroughly upon entering the room and scrub the hub with alcohol for over 15 seconds - it's best practice to wear gloves when hooking anything up or touching a central line. If anything else it eases a pt's fears about any bacteria entering their line.
8. Remember that a LOW temperature can be a sign of sepsis, just as much as a fever. Don't discount this in your sepsis assessment just because a pt doesn't have a fever. I did this erroneously this past week and my preceptor caught it and, with this one added piece of information, notified the MD that the pt screened positive for sepsis (which, incidentally, she was already being treated for).
9. Make note of all timed blood sugar checks on your brain with little check boxes, particularly the ones where there is no insulin ordered as a reminder to you (such as post-pradial sugar checks). I forgot to check post-prandial sugars in one of my pts after breakfast and lunch because they didn't have any insulin ordered and it just slipped my mind.
OK, there you go. Some mistakes from just a few weeks on the new job! We need each other if we're going to practice nursing safely! Thanks to the author of this original thread and all the nurses out there that have responded so that we can ALL learn from each other's mistakes.
God was with me on that one.
calivianya, BSN, RN
2,418 Posts
It's nice to see that everyone makes mistakes. :)
I made one during my preceptorship. It was not uncommon on this floor for nurses to really help each other out - give so and so some insulin for me, draw up some insulin for me, can you change a rate on X, etc. Well. I told my preceptor what the patient's CBG was and she volunteered to go draw up some insulin. Key word: some. I think she had said at some point that she had drawn up 10 units of insulin, but I was thinking about something else and it just went in one ear and out the other. The patient only needed 2 units, but it was pretty common on the floor for a helping nurse to draw up maybe 10 or so units so the person at the bedside who was tied up could waste the rest in the sink and then give an appropriate amount. In my absent-mindedness I did not look at the syringe other than to hold it, assuming my preceptor had checked the MAR and drawn up the correct amount, and did not waste any of the insulin in the sink but instead gave the full 10 units to the patient.
I got that feeling that something wasn't quite right immediately after I gave it, asked my preceptor how many units she'd drawn up, and got that funny feeling that ran through my whole chest and felt like someone was applying an ice pack to my sternum. Fortunately, the guy was on continuous enteral feedings and I checked the CBG pretty often and his never dropped below 100. In fact, that was one of the first times his blood sugar had been under 200, so maybe the sliding scale needed to be adjusted, or the feed formula needed to be adjusted, or something. Either way, he was fine, and I learned that if anyone else hands me anything that I've asked them to bring, should the occasion arise, that I should NOT trust that they got it right and should definitely check the med again myself before giving it. I will remember that awful ice cold feeling forever, and I hope I never feel it again!