Your Worst Mistake

[aurora_borealis]

Here's mine:

I was working a night shift, which to this day I truly detest. When I got report, I found I had a patient in acute alcohol withdrawal (which in and of itself makes me furious, because there is no excuse for a hospitalized patient to suffer DT's if someone knows what they're doing, but I digress.)

Anyway, back to this unfortunate soul.

Because he was delusional and combative, he was restrained so he couldn't yank his IV out for the 10th time. They had also wrapped his IV site with kerlex as an added precaution...maybe if he couldn't find it he'd leave it alone. He was also being transfused with a couple of units of blood.

When I got there, he was nearly through the first unit, and I was to finish that and hang the next one. Well and good. Or so I thought. I started the second unit, but I had one hell of a time infusing it. I literally forced it in with the help of a pressure bag, and I am not kidding when I say it took a good 6 hours to get that blood in. Meanwhile, the patient was getting more and more agitated, which I attributed to his withdrawal.

Finally, mercifully, the blood was in so I opened up the saline to flush the line. But it wouldn't run. All of a sudden I realized, with absolute horror, what had happened.

I cut off the kerlex covering the IV site hoping against hope I was wrong, but alas, I wasn't. Yes indeed, I had infiltrated a unit of blood. I hadn't even bothered to check the site.

No wonder he was so agitated, it probably hurt like hell.

An hour later my manager showed up, and I told her what happened. She was probably the most easy going person I've ever known, and she told me not to worry about it.

I said "Listen to me, I infused an entire unit into his arm, go look at it." She did, and came out and told me to go home. I expected consequences, but never heard another word about it. But I am here to tell you I learned from that mistake.

[zacarias, ASN, RN]

. He did a full assessment on my son since he had never seen him before, thank goodness. Anyway, he heard a murmur, which had never been heard before, and got a horrible look on his face, and said that we need to go to a ped. cardiologist within the next week. !

Brenda,

I'm in WA too. It sounds like you and your familiy have been through a lot. May I ask what the heart condition was?

[silvermaple2rpn]

Guess what, everyone is going to make a medication error. It is inevitable. believe me, you will make a mistake, but you will learn quickly from it, and once you make a mistake it is most likely you will not make the same one again. Experience is what makes compitence and learning from our mistakes is the best experience.:) My director of nursing says that they expect to see med error reports for every nurse in the facility once in awhile. You figure the amount of medication you give out in a day adds up to 100's of pills in a month. They tend to worry more if they never see an error being reported, it is most likely then that someone is covering up their errors.

[Brenda-RN,BSN, WA.]

It's called anomolous left coronary artery from the right sinus of valsalva. I'm an ob nurse, so this was greek to me. His left coronary artery was running in between his pulmonary artery, and his aorta. I guess there are no symptoms, usually with this, they just drop, very scary. We just feel so blessed to have found it, and been able to have it corrected. Thank you for your reply. Are you a cardiac nurse?

Brenda,

I'm in WA too. It sounds like you and your familiy have been through a lot. May I ask what the heart condition was?

[terri0318rn]

I whole heartedly agree with this response....You must forgive yourself. I know you feel the guilt. My mother passed away last year from what I call Chemotherapy Overdose. She lived 2 and 1/2 hours north of me and I could not be with her as much as I would have liked. I didn't have a good connection with her onologist. By the time I took charge, it was too late. I had been a nurse for one year on an oncology floor and knew my stuff. But now, my best friend, one of the most intelligent people I will ever now, the most generous and compassionate people, My Mother is now with God. I feel the guilt for her loss. I feel like I should have done more......but there are doctors who are supposed to know what they are doing. And other nurses who are supposed to have been her advocate. She is the reason I am the nurse I am today. (thank you mom) I know in my heart that it is not my fault............Please for give yourself. I know it is not much comfort, but as my mother would say, things happen for a reason. Maybe you are supposed to be where you are. My heart goes out to you.

Incidently, my biggest mitake was in hanging an insulin piggyback and programing it to what the pharmacist and resident told me to I didn't question it when they told me 100 when it actually should have been 10 or something like that....it has been a while, but the daughter in law of the patient was a nurse on another floor in the hospital and happened to look at the piggyback and brought it to the attention of the nurse manager.......This occured after I had left the floor to go home one night. A case of the daughter in law being educated and in the right place at the right time......I know I should have known to double check, but I had 7 patients (she was a new admit with uncontrolled blood sugars and it was 1 hour before end of shift)

Write me if you [email protected]

Good luck in what ever you do........and God Bless you:nurse:

Terri

The first rule of emergency medical services is to secure the scene-their safety is paramount.You could have gotten hurt yourself had you tried to be more assertive

.You have NOTHING to be forgiven for-you were surrounded by drunks and you did all you could have done.Had you resisted the brother's attempt to help he would have smacked you flat.ETOH and the brother killed the victim-not you...As for the rest of the family do they blame you? Has it affected your marriage? You can go back and get the proof you need to clear yourself of blame but is it worth it?Will it cause more harm to all involved? I am betting the brother does know what he did-why not talk to him with your husbands help? Have you ever gotten counseling ? I think you should...You did all that you could and you have to believe that before you can heal yourself......

[terri0318rn]

I had a patient just the other day who had an inulin regimen at HS. I worked 2 nights in a row and this lady had a 26 BS one night and a 29 the next morning after adjustments having been made to her regimen. I am at a new job and am still technically in orientation but I had never had a patient with that low of a BS before. Good thing I had a preceptor......blessing in disguise. I had never had to get Dextrose before and would not have known the protocol. SO, I had the preceptor the 1st night, the 2nd I was on my own......Hello pharmacist and hello moonlighter physcian. I found out that you sometimes have to act first act and get the Dextrose and call for the physician to ign the order after the fact. My adrenaline was surely at its peak that morning!:imbar WOW.

I think most medication errors I have read about here have to do with insulin. there has to be something we can all do to eliminate the errors, which will continue no matter what we do........we are human first

Did you write it down anywhere? If not, I still think it would be better to keep it on the QT. You can't change it now it's been too many hours.

A little less insulin is better than too much. I've had many more problems in my 12 years of nursing with patients bottoming out on blood sugars than elevated ones. The last one wasn't my patient but I helped a nurse recently with a patient who had a BS of 35. Let me tell you it was scary......

The scariest for me was a student in middle school who didn't take her diabetes seriously and varied between the 40's to the 600's......now that was no fun at all.

Keep your chin up......you can write back again and I'll answer.

[watersnake]

Wellll.....

I was charge in an E/P lab. The fellow I was working with was a Preacher's kid, you know the kind, a little bit of devil there but a great guy.

We're getting a little frail old woman on the table, and I notice a bad bruise on her arm and head. I usually keep up a banter to distract pt.s from the situation, on neutral topics. I asked her what she did to herself, and she told me she fell down an escalator. I said "Oh my gosh, was it going up or down?" She said it was going up, to which I responded without thinking, "Man it must have taken a long time to get to the bottom."

My partner looked at me trying to stifle a laugh, with tears in his eyes, walked outside the lab and I could hear the laughter. Well that set me off, and I acted like I was coughing, and all those things you do to try to disguise a laugh. Then every time he looked at me during the case, it started all over.

Thank God for Versed and amnesia.....Snake

[MelissaRN]

I was working as a new nurse about 4 months into the job. I had a post op hip surgery patient that I got from PACU in the middle of the night. I was in and out of the room all night doing post op vital signs and making sure she was comfortable. I was making sure to check her dressing periodically to make sure that it was intact and without alot of drainage. What I didn't see was a board that the X-ray tech had stuck under her when doing post op x-rays. It was underneath the draw sheet because I didn't see it.

Well it was found a few hours later by day shift. It really hit the fan. I was mortified that it had happened absolutely mortified. To add insult to injury I didn't find out about it until a week later after everyone in the department had talked about it. Of course I had no recollection of the night in question as it was a whole week later. I had worked a four night stretch and had a stretch off. You can bet your butt that I now look underneath the drawsheets when turning my patients. The PACU nurses give me strange looks when I'm reaching under the patients when they come to the floor. If I ever find one I'd be personally handing it back to the X-ray tech.

And I'm not the only nurse that this has happened to either. After that incident 3 more cases of that were found.

[nursemjb]

I was working as a new nurse about 4 months into the job. I had a post op hip surgery patient that I got from PACU in the middle of the night. I was in and out of the room all night doing post op vital signs and making sure she was comfortable. I was making sure to check her dressing periodically to make sure that it was intact and without alot of drainage. What I didn't see was a board that the X-ray tech had stuck under her when doing post op x-rays. It was underneath the draw sheet because I didn't see it.

Well it was found a few hours later by day shift. It really hit the fan. I was mortified that it had happened absolutely mortified. To add insult to injury I didn't find out about it until a week later after everyone in the department had talked about it. Of course I had no recollection of the night in question as it was a whole week later. I had worked a four night stretch and had a stretch off. You can bet your butt that I now look underneath the drawsheets when turning my patients. The PACU nurses give me strange looks when I'm reaching under the patients when they come to the floor. If I ever find one I'd be personally handing it back to the X-ray tech.

And I'm not the only nurse that this has happened to either. After that incident 3 more cases of that were found.

And this is such a big deal because.... Did it hurt the patient in any way???? I can think of a lot worse things than this.

[GEO]

I Have Two That Haunts Me To This Day.

#1. It Was 1980 And I Was Working In Icu. Brand New Nurse (no Excuse). Did Pray In The Bathroom Prior To Going On My Shift For The Lord To Watch Over My Patients.......which Turned Out To Be A Very Good Idea. The Old Iv Pumps Could Accomodate Both A Mini-drip Tubing System And A Macro-drip Tubing System. This Little Gentlemen Had Recurrent V-tach And Was On A Lidocaine Drip. When I Rehung The Bag I Spiked It With A Macro Tubeing...not A Mini Drip Tubeing...i Was Off The Next 2 Days. Came Back And Found Out By My Charge Nurse That It Took Almost 2 Shifts To Realize What Had Happened. He Slept Well, Did Not Have Any Ill Effects Except Did Have Speech That Was Slurred. I Was Devastated......i Was Seriously Quitting. My Charge Nurse Set Me Down, And While She Was Stern, She Was Also Kind And Talked To Me. I Think About This Mistake And Her Often. Will Never Forget It.

#2. 11-7 Lpn Gave Me Report And Reported A B/p That Was Fine, 146/76 For A Little Gentleman. I Wrote The B/p She Quoted Me On My Report Sheet. I Gave His Am B/p Medication Without Taking The B/p Myself. In A Bit I Came Back, Going To Get Him Ready For Breakfast And He Was Not Alert. I Immediately Did V/s And Assessed Him. Went Back To The Mar And There In The Chart A Much Lower B/p Had Been Charted By The Nite Nurse. Like 80's/40's. It Was A Nightmare Of A Day. He Ended Up Fine, I Wasn't. While I Was Angry With The Lpn, I Also Recognized My Error. Never Give A B/p Med On Someone Elses Word. I Check It Myself And Give It Myself. While Both Errors Did Turn Out With The Patient Having no lasting effects. I Will Never Forget. I STILL PRAY IN THE BATHROOM BY THE WAY........

[kc ccurn]

In nursing school, one of our instructors always told us that we didn't make mistakes, we had major learning opportunities. Some bigger than others. 12 years later I still think of that. With nursing, and life, it's not a matter of if you'll make a mistake, the question is when. Learn from your mistakes, be responsible and own up to it and most importantly learn from your mistake. That's one of the differences between a newer and a seasoned nurse. Get into a routine with medication delivery, assessments, VS, reassessments, charting, reporting, etc. Getting into a routine that is thorough makes it easier to listen to that small quiet voice in the pit of your stomach that is telling you something isn't right.

[nursemjb]

In nursing school, one of our instructors always told us that we didn't make mistakes, we had major learning opportunities. Some bigger than others. 12 years later I still think of that. With nursing, and life, it's not a matter of if you'll make a mistake, the question is when. Learn from your mistakes, be responsible and own up to it and most importantly learn from your mistake. That's one of the differences between a newer and a seasoned nurse. Get into a routine with medication delivery, assessments, VS, reassessments, charting, reporting, etc. Getting into a routine that is thorough makes it easier to listen to that small quiet voice in the pit of your stomach that is telling you something isn't right.

How did you get the Tigger under your screen name?

[kc ccurn]

How did you get the Tigger under your screen name?

In the yellow tool bar at the top of the page, click on user cp, then on the left hand menu, click on edit avitar. This will give you a choice of avitars to choose from. I chose the tiger because he reminds of Tigger and the tiger from Calvin and Hobbes...sooo cute.