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.

[Ruby Vee, BSN]

My error has kept me from working since the day it happened. I so terrified that I may make another mistake which may lead to a patients crash or even death. It was a busy day and I was overwhelmed (still no excuse) and my patient was on a sliding scale insulin. I took the blood sugar and she required FIVE (5) UNITS of insulin. to this day I do not know what was going through my mind but I pulled back to FIFTY (50) UNITS instead of the minimal FIVE (5) she needed. I did my checks that it was the proper insulin. I took the patients medication profile to her bedside and compared her armband to the profile and I stated to her that I was there to administer her insulin.

Still not knowing that I had done the error I left the hospital at the end of my shift which was about 45 minutes later. I had helped her with her tray and asked her if there was anything I could do for her before I went off shift. (because sometime report & shift change take a while), she replied no.

I was at dinner with my husband at a resturant and while eating my soup, which was the first part of my meal, IT HIT ME WHAT I HAD DONE! My husband saw my face and asked me what was wrong I immediately grabbed the cell phone and tole my husband to just leave money and drive me to back to the hospital. I called the unit and told them about the error - they said 50!?!?!?!?! I said yes I will be there in 5 minutes. They changed her iv fluid to 50% dextrose and ran it at 100/hr. I stayed with her doing continuous bld sugar tests until midnight. Her BLOOD SUGAR never dropped below 8.1 - in Canada (Ontario) normal blood sugar levels are between 3 and 7.

I was praised and praised for coming back and admitting my mistake. I haven't worked as an RN since.

People make mistakes, and I'm assuming that you, like the rest of us are only human. You admitted your mistake and went out of your way to rectify it. That makes you an honorable and ethical nurse. There are no perfect people, and there are no perfect nurses. I'll take an honest and ethical nurse over nonexistant perfection any time.

You are going to make mistakes in life whether you work as a nurse or not. I think the profession needs MORE honest and ethical nurses, not less. Nurses, being human, will always make mistakes. The best anyone can do is honestly admit to them as soon as realizing that a mistake has been made, and then doing everything possible to rectify the situation.

A friend of mine once made a horrible drug error that killed a patient. I have know idea how she found the strength to continue nursing -- but she did, and she's now one of the best nurses I know. Still honest and ethical as well.

[Agnus]

My error has kept me from working since the day it happened. I so terrified that I may make another mistake which may lead to a patients crash or even death. It was a busy day and I was overwhelmed (still no excuse) and my patient was on a sliding scale insulin. I took the blood sugar and she required FIVE (5) UNITS of insulin. to this day I do not know what was going through my mind but I pulled back to FIFTY (50) UNITS instead of the minimal FIVE (5) she needed. I did my checks that it was the proper insulin. I took the patients medication profile to her bedside and compared her armband to the profile and I stated to her that I was there to administer her insulin.

Still not knowing that I had done the error I left the hospital at the end of my shift which was about 45 minutes later. I had helped her with her tray and asked her if there was anything I could do for her before I went off shift. (because sometime report & shift change take a while), she replied no.

I was at dinner with my husband at a resturant and while eating my soup, which was the first part of my meal, IT HIT ME WHAT I HAD DONE! My husband saw my face and asked me what was wrong I immediately grabbed the cell phone and tole my husband to just leave money and drive me to back to the hospital. I called the unit and told them about the error - they said 50!?!?!?!?! I said yes I will be there in 5 minutes. They changed her iv fluid to 50% dextrose and ran it at 100/hr. I stayed with her doing continuous bld sugar tests until midnight. Her BLOOD SUGAR never dropped below 8.1 - in Canada (Ontario) normal blood sugar levels are between 3 and 7.

I was praised and praised for coming back and admitting my mistake. I haven't worked as an RN since.

I will praise you too, though you probably do not undrstand why. The reason is you did not do this from neglect or malace. It was a VERY human error. You corrected it an no harm resulted.

Human beings make errors every day. It is part of being alive. ALL nurses are human. The issue is not that you made an error. The issue is that you made and error and followed though with action that corrected it and avoided harming a patient. It is impossible to avoid all errors.

I am sorry that you have discarded a wonderful oportunity to grow because you are unwilling to accept that harm could result from your careful actions. If every nuse, every physician, every person, felt as you do, we would have no physicians or nurses at all to do the work (though imperfect) they do.

[Bonnie Blue]

I am a new grad working on a med surg floor. I made a med error today. This is not the first time I have made an error in the six months I have worked on the floor. I owned up to it but I am just sick. I have tried soo hard not to let this happen. I write down when my meds are due, I check and re-check the MAR and still I have made several errors in time I have been working. Please don't crucify me. I have talked to my head nurse about it and will go in again tomorrow voluntarily to try and do something. I want the experience that comes from working on a med-surg floor but I am afraid I am really going to hurt someone.

[GLORIAmunchkin72]

My worst mistake was when I gave a nursing home pt who'd had a hip done his pain and BP med at the same time without first checking his BP. I was usually supervigilant about checking bp's before I gave meds. Anyways, after an hour, his BP was 88/55 and I was FREAKING!!! I didn't care if it was the middle of the night, I still called the surgeon. I trended him, had him on q15 min vitals and basically prayed all night. I just knew I had killed that pt! He recovered fine, but scared me to death, especially since he couldn't communicate other than moans due to advanced dementia.

Many of our residents have lower than "normal" BPs and a lot of them are laying down all of the time and it's not usual for us to get 88/55. I have seen some lower than that and wondered how they stayed alive.

[michelle95]

Let me share a couple since I think we are all learning from each other (I know that I am).

First, I set up meds in the room one time and still gave the wrong patient the wrong pills (her roommate's). I was distracted by talking. Thank God that the patient was a dialysis one and scheduled to get dialysis in a few hours. She turned out fine.

The second one haunts me. Had a patient on prednisone. It was being decreased. I worked 11-7 one night (to help out, of course) and when I checked the new daily mars to the old ones, I didn't make sure the predisone was still on there. Pharmacy missed it on printout, and, I missed it when checking.

In the next day or two the patient started having pain from the abrupt stop of prednisone. The doctor kept increasing pain meds. Long story short, the lady died of a bowel obstruction. I forgot all about the prednisone until I heard the doctor ask why she hadn't continued prednisone. I went to check the MARs of the 11-7 that I worked (the only one in months) and sure enough that is when I realized that I had missed it.

To be fair, the little old lady was very sick..although I can't remember what exactly she was in the hospital for. However, I can't help wondering how it would have turned out if I wouldn't have missed that prednisone.

Always, always, be careful when turning over MARs.

[redwinggirlie]

Letting family stay on the floor afer hours.

Big no.

[moia]

Once many many moons ago..I had a nitro gtt...my patients BP was way too high so i set the pump to bolus for a set amount of time...or so I thought......instead I had reset the main pump and the timer backwards......big bolus over very short time...I couldn't figure out why my patients BP was barely there until the pump alarmed time up.....thank goodness they bounced right back but for that 1 minute I was holding my breath.

[weetziebat]

well, the biggest mistake i ever made was a long time ago but still makes my blood run cold to think about it.

[color=#4b0082]i was working in a newborn icu, taking care of an infant who had just returned from surgery after having a central line put in. unable, no matter how hard i tried, to remove the tape from his dressing, which was a mess, i did what every nurse knows better than to do - i pulled out my bandage scissors to cut the tape. yep - also cut the line. i was so stunned that i could have made such a stupid mistake. just stood there for a minute like i could turn back time, then called the doctor. the baby had to go back to surgery to have another line put in, and after that it took me a long time to regain my confidence. everyone, from the neonatologist to the other nurses were all so understanding and supportive. and no one mentioned how stupid it was to use scissors in the first place, and for that i was most appreciative.

[color=#4b0082]can't imagine how one must feel to have a patient die after a mistake.

[DG5]

A second year student, thrown into ICU for the first time, told to watch a patient out of surgery from triple bypass, tubes everywhere, told to do vitals Q 2 hourly, temp was really low, cold extremities, told to get a blood warmer. The charge RN set it up but no one told me now to watch vitals more often. Two hours later, he is gesticulating at me in a frantic way, I couldn't figure out what was wrong. The Dr came around, asked me when his last temp was taken, I said two hours ago, he just about flipped and when I took the temp it was 40 something. The blood warmer came off stat, I left the shift crying and didn't sleep the whole night, was there at 6 am the next day to enquire if he was okay.

Thinking back, it was ridiculous, the RN in charge was not there for me. I realised only years later that it really wasn't my fault. But I beat myself up over it for a long time.

[nycegyrl]

when i grow up to be a nurse i know i will make mistakes. i already worry about them. i made a mistake when i was a med tech. i put ear drops in a ladies eye. of all things. :chair:

[coocooclown]

Hello all!!! I am a paramedic and have been in ems for about 10 years now...and have made a few goofy, but not necessarily harmful mistakes. I will write them off as a result of sleep deprivation.

Anyway...I have attempted to intubate someone before with a trach. :stone prior to doing an assessment. Once I figured this out, it then made sense why I couldn't pass the tube.

And I set up an albuterol treatment to administer to a man with COPD with a BP of 240/130....I'm so glad that a bell went off prior to doing this. :imbar.

I'm sure there are more instances...I'll have to get back on that one.

[boulergirl, CNA]

I've made two mistakes recently as a med tech.

#1: Putting oxygen on someone without a doctor's order. We had a resident who had trouble breathing one night. When I reported to work the next night my boss' assistant called into the office and told me that if this resident had problems breathing we have another resident who uses oxygen--get one of his tanks and use it. Trouble is, he has a dr.s order for oxygen and she doesn't. The boss' assistant never told me how high to set the O2, either, so I set it no higher than the 1-liter mark. (Didn't want to blow her lungs out.) I later learned that it does no good below the 2-liter mark.

When I was instructed to do all this, I had misgivings about it but didn't want to call the nurse at home and wake her up. Thankfully, when she came the next morning she didn't write me up. She just reminded me that O2 needs a dr.'s order and to PLEASE call her any time if I don't feel right about something. (The boss' assistant is an NA, but tends to play nurse.)

#2: Giving meds without checking to see if the resident is swallowing them. BIG mistake. I gave pain meds to a resident every 3 hours as instructed and his pain was not getting better. Turns out he was holding them in his mouth. The family was livid when they found out. Now I make SURE that pain pill goes down.