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.

[jeepgirl, LPN, NP]

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.

If a resident is having a suddent onset of breathing trouble, I would almost call an ambulance or take them to the ER. it can indicate many, many things and no one wants someone to check out on their shift!

[boulergirl, CNA]

If a resident is having a suddent onset of breathing trouble, I would almost call an ambulance or take them to the ER. it can indicate many, many things and no one wants someone to check out on their shift!

You know how they say hindsight is 20/20? Believe me, I would have done a LOT of things differently if I had that night to do over. 911 would have been called, the nurse and the family would have been called. No questions. The nurse sent her out the next morning and turns out the resident had pneumonia. Great. :uhoh21: (She's okay now and coming home this week, but I still feel rotten.) I've also learned to second-guess the boss' assistant when she gives instructions about a resident.

[jeepgirl, LPN, NP]

You know how they say hindsight is 20/20? Believe me, I would have done a LOT of things differently if I had that night to do over. 911 would have been called, the nurse and the family would have been called. No questions. The nurse sent her out the next morning and turns out the resident had pneumonia. Great. :uhoh21: (She's okay now and coming home this week, but I still feel rotten.) I've also learned to second-guess the boss' assistant when she gives instructions about a resident.

don't feel rotten. i would say that you did better than some would have done: at least you tried to put O2 on her instead of letting her struggle to breathe... thats better than some would do!

[reipie]

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.

That' so sad that you didn't go back to nursing after that. Were you a RN for a long time? I am in pre-nursing school now and I dread the day my first med mistake happens.

God bless.

[bcjams]

i made a mistake once...and i still cannot talk about it....no one got hurt but me...pt is ok...and i am a better nurse because of it...double check your work. ..it takes less time than the mental beatings will later on.

I still remember it every time i start to do something that has to be done right the first time....it makes me a good nurse.

[bcjams]

The bizarre thing is that the Rn who discovered it offered to keep it quiet because her new orders would correct the situation but I reported it to the MD and my supervisor ...the pt comes first.

[EricTAMUCC-BSN, BSN, RN]

I don't make mistakes... I'm 100% right! Turned off tube feedings on a patient in orientation and didn't turn off the insulin drip. The blood sugar was 20, pushed dextrose and it came up to 90.

[tridil2000, MSN, RN]

Well, with everyone admitting their errors, here's my worst error:

Fresh out of school in 1984, as a GN, working night shift with 15 pts (me and an aide), I had to flush all the saline locks. Back then we had boxes of hep lock flush, potassium, and benadryl on top of our med carts. Each box held about 24 sindgle doses of each med. I used to come in an draw up all my flushes to give during my first rounds..... Well I guess you can figure this out by now:crying2:

As the shift ended, I realized that I had a full box of hep lock flush and I had flushed everyone with Benadryl!

:imbar

Well, everyone got a good night sleep that night anyway! I still get goosebumps thinking about that!

lmao!

are you sure that was a mistake!

my first year in er i gave the adult tylenol suppository to a toddler!

[oncbsnrn]

I had a post-op total hip patient about 75 years old. She had a Demerol PCA ordered for pain control. The initial bolus was to be 10mg. So......I set the pump to deliver 10cc. Only problem was the concentration was 10mg/cc so I had set the pump to deliver 100mg. I realized I had set the pump to deliver the morphine dilution for 10mg. I remember getting an ambubag and narcan to the bedside and then calling the doc, who I thought would ream me out. He was actually very understanding. Patient was ok and never required narcan.

Funny thing was, when I came in the next day, the patient said...I'm so glad to see you! I haven't been as comfortable as when you were my nurse last night.

[apaisRN, RN, CRNA]

Funny thing was, when I came in the next day, the patient said...I'm so glad to see you! I haven't been as comfortable as when you were my nurse last night.

I love that one! Off the top of my head I'm thinking 25-100 mg of Demerol is a normal first dose, but I haven't given it in a dog's age.

The one I think is funny (but still not okay, obviously) is the day I had two very similar ICU patients side by side. Female, close in age, both vented, similar diagnoses. One had thyroid med IV ordered and the other didn't. Busy day, lots of new orders, you can guess what happened - the wrong one got the med. I reported it and did the paperwork and the docs were totally unconcerned. Later I was reading through the accidently-medicated pt's chart and found that she, too, was hypothyroid! I probably did her a favor, giving her a med she needed.

[Dorito, ASN, RN]

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.

Just remember the 5 rights. Double or triple check before you give meds and just know mistakes happen. I hung PCN on a patient that was allergic to it. She started itching within 15 minutes. She was fine but sure scared me. Many of the errors nurses make don't even get reported. Good luck to you.

[Aneroo, LPN]

I have an instructor who has made ONE mistake during her career as a nurse. She's proud of it, and she said it is because she ALWAYS checks her five rights. How easy that concepts slips away from us.

I'm actually on medication probation until graduation, but not because of a med error. I gave a med without my instructor. I had just got off a cardiac unit where we were very indepedent. We were allowed to give meds without the instuctor. First week on floor with new instructor, who wanted to be there with us for everything, even saline flushes of PIV. I had called the pharmacy yo verify something about a med, and was waiting on hold when she came around. Told her what was going on, and she said to get her when it came up. When it came up, I went ahead and gave it (Tums and MOM!). So, when she came around, she asked if I was ready, said I already gave it. That's when I realized she had wanted to be there with us, and I knew I was in trouble. I went first thing the next class day to the lead instructor to tell her what happened. I checked my Medex and did my 5 rights. I just didn't get the instructor to do it with me. I was able to pull the packaging out of the trash so she could verify the dose and drug. So, now I am required to have the instructor with me for all meds, while other students are giving meds with the RN now, not the instructor. I had to do a big write-up on why I made an error, and I made sure to put at the bottom that my error was in not checking with the instructor, and not an error with the med. -Andrea