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.

[nursemjb]

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.

Thank you very much!!!!!

[KibbsRNstudent]

Thanks you, thank you, thanks you all for these stories. I start my clinical rotations this fall and as much as I can't wait, I knwo that I need ot keep my excitement of all the newness in check at all times and focus because I want to learn form mistakes made and try to never make them myself. I do know that fessing up is a hard thing to do and kills the pride but "Pride goeth before the fall" so it is always better to fess up and do the right thing. If you don't fess up you may kill the pt but if you fess up and STAT then you may save the persons life(even if you are the reason they could have lost it)

[KibbsRNstudent]

Thanks you, thank you, thanks you all for these stories. I start my clinical rotations this fall and as much as I can't wait, I knwo that I need ot keep my excitement of all the newness in check at all times and focus because I want to learn form mistakes made and try to never make them myself. I do know that fessing up is a hard thing to do and kills the pride but "Pride goeth before the fall" so it is always better to fess up and do the right thing. If you don't fess up you may kill the pt but if you fess up and STAT then you may save the persons life(even if you are the reason they could have lost it)

[mscsrjhm]

Early '80s, new nurse, Rookeyitis, new ACLS. Elderly fe in ER, extremely diaphoretic, pale, very low BP, change in MS. The Dr. was 15 minutes away, by the time he arrived, ME--Ms. Perfect ACLS nurse-- had every thing ready... 12 lead, blood was even drawn, spinning down, two IV lines, meds given, even ABGs. Wow, I was really special. UNTIL, the Doctor told me what a wonderful job I had done,then said "do you think she could use some oxygen?".

Rookeyitis gone. Perfect cure.

[mscsrjhm]

Early '80s, new nurse, Rookeyitis, new ACLS. Elderly fe in ER, extremely diaphoretic, pale, very low BP, change in MS. The Dr. was 15 minutes away, by the time he arrived, ME--Ms. Perfect ACLS nurse-- had every thing ready... 12 lead, blood was even drawn, spinning down, two IV lines, meds given, even ABGs. Wow, I was really special. UNTIL, the Doctor told me what a wonderful job I had done,then said "do you think she could use some oxygen?".

Rookeyitis gone. Perfect cure.

[rEAL nUT]

As A Critical Care Nurse I Frequently Assist The Doctors With Putting In Central Lines, A-lines, Swans Ect. Well On One Particular Day While Assisting The Doctor To Put In A Swan On A Very Unstable Pt (hince The Need For The Swan) I Was Setting Everything Up, And Of Course We Had Recently Changed Monitors Which Required The Swan Set Up To Be Different From What We Were Used To, But I Was Very Sure That I Had Set It Up Correctly All By Myself For The First Time. Once The Doctor Was Ready To Float The Swan I Inflated And Deflated The Balloon As He Requested. We Tried For At Least 20 Minutes Advancing The Catheter And Taking It Back Out, Without Being Able To Get The Swan To Wedge. After Causing A Few Ectopic Beats And, Rechecking The Set Up With Another Nurse (of Course The Doctors Don't Know What The Set Up Should Look Like) And Still Not Getting The Swan To Wedge The Doctor Decided To Leave The Catheter In Place And Have A Chest X-ray Done. Before The Chest Xray Was Done We Noticed That Although My Setup Was Correct My Transducers Were Not, And The Catheter Had Been In The Correct Place All The Time. The Patient Did Well, But I Hate That She Had To Go Through More Than What Was Necessary For Her Care, Because She Had Already Been Through So Much. Thank God For Fentanyl And Versed Gtts.

[rEAL nUT]

As A Critical Care Nurse I Frequently Assist The Doctors With Putting In Central Lines, A-lines, Swans Ect. Well On One Particular Day While Assisting The Doctor To Put In A Swan On A Very Unstable Pt (hince The Need For The Swan) I Was Setting Everything Up, And Of Course We Had Recently Changed Monitors Which Required The Swan Set Up To Be Different From What We Were Used To, But I Was Very Sure That I Had Set It Up Correctly All By Myself For The First Time. Once The Doctor Was Ready To Float The Swan I Inflated And Deflated The Balloon As He Requested. We Tried For At Least 20 Minutes Advancing The Catheter And Taking It Back Out, Without Being Able To Get The Swan To Wedge. After Causing A Few Ectopic Beats And, Rechecking The Set Up With Another Nurse (of Course The Doctors Don't Know What The Set Up Should Look Like) And Still Not Getting The Swan To Wedge The Doctor Decided To Leave The Catheter In Place And Have A Chest X-ray Done. Before The Chest Xray Was Done We Noticed That Although My Setup Was Correct My Transducers Were Not, And The Catheter Had Been In The Correct Place All The Time. The Patient Did Well, But I Hate That She Had To Go Through More Than What Was Necessary For Her Care, Because She Had Already Been Through So Much. Thank God For Fentanyl And Versed Gtts.

[stevierae]

wow, this is so much like my biggest error. I did the exact same thing. Instead of pulling up 4 units, I drew up 40. Even when the pt said, "why is there so much in the needle?" it didn't click. Like you, it was much later in the day when out of the clear blue it hit me. I immediately called work, and they informed me that she had bottomed out, but was currently stable. I reported my error to the DON, but even with her reassurance, I lost a lot of confidence in myself.

Not criticizing anybody, but aren't nurses taught in nursing school anymore to double check heparin and insulin with another RN while drawing it up? That's what I was taught, both as a hospital corpsman in the aNavy 30 years ago, and when I went to nursing school (i graduated in '81.) I still do it to this day--always, always, always--check my insulin and heparin with another RN, or a surgeon, or an anesthesiologist as I draw it up. We verify what the label says together, and what's drawn up in the syringe. The more I read, I am fearful that this simple technique is not being taught anymore.

[stevierae]

wow, this is so much like my biggest error. I did the exact same thing. Instead of pulling up 4 units, I drew up 40. Even when the pt said, "why is there so much in the needle?" it didn't click. Like you, it was much later in the day when out of the clear blue it hit me. I immediately called work, and they informed me that she had bottomed out, but was currently stable. I reported my error to the DON, but even with her reassurance, I lost a lot of confidence in myself.

Not criticizing anybody, but aren't nurses taught in nursing school anymore to double check heparin and insulin with another RN while drawing it up? That's what I was taught, both as a hospital corpsman in the aNavy 30 years ago, and when I went to nursing school (i graduated in '81.) I still do it to this day--always, always, always--check my insulin and heparin with another RN, or a surgeon, or an anesthesiologist as I draw it up. We verify what the label says together, and what's drawn up in the syringe. The more I read, I am fearful that this simple technique is not being taught anymore.

[stevierae]

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.

EXACTLY. I think those nurses who talked about it for a week were just being jerks. I've seen patients come to surgery with the wooden board that is slid under them during resucitation from cardiac arrest (CPR, defib, the whole 9 yards of a code) still under them. Look and see when the code occurred--oh, 48 hours ago or more....no harm done, though....

Don't let this incident with the X-ray cassette bother you, Melissa. Trust me, they just had nothing better to gossip about that week.

[stevierae]

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.

EXACTLY. I think those nurses who talked about it for a week were just being jerks. I've seen patients come to surgery with the wooden board that is slid under them during resucitation from cardiac arrest (CPR, defib, the whole 9 yards of a code) still under them. Look and see when the code occurred--oh, 48 hours ago or more....no harm done, though....

Don't let this incident with the X-ray cassette bother you, Melissa. Trust me, they just had nothing better to gossip about that week.

[Tweety, BSN, RN]

Not criticizing anybody, but aren't nurses taught in nursing school anymore to double check heparin and insulin with another RN while drawing it up? That's what I was taught, both as a hospital corpsman in the aNavy 30 years ago, and when I went to nursing school (i graduated in '81.) I still do it to this day--always, always, always--check my insulin and heparin with another RN, or a surgeon, or an anesthesiologist as I draw it up. We verify what the label says together, and what's drawn up in the syringe. The more I read, I am fearful that this simple technique is not being taught anymore.

To be honest with you, I wasn't taught that in school, and I'm not a new nurse. (Of course we checked and doubled checked all meds with our insturctor.) So for a while I wasn't checking insulin with anyone until I read it was policy after noticing a few people come to me to double check. They usually come with the needle and not the order, the accucheck or a copy of the med sheet. And no double-signing of the med sheets. But still this helps with big orders because if someone comes with 40 units of Regular a big red flag would come up.

But surely you've been around long enough to know that what you're taught in nursing school and the real world isn't always true. :)