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.

[MrsStraty]

We were taught "Did I Kill Him" to remember the names of the medications which have the greatest potential for harm if given incorrectly:

D : digoxin

I : insulin

K : postassium

H : heparin

NurseFirst

I like that one.....Did I kill Him.

Here in Dutchess County, NY we do NOT have to check insulin with another nurse. I graduate in May 2005 and I have given insulin plenty of time and never heard of that rule. Also I work at a hospital where I have never seen the nurses double checking insulin.

MrsStraty

:balloons: ADN grad in 11 weeks!

[busylynn]

I too follow those same rules when passing meds. It has saved my behind more than once. A lot of my coworkers think that I am a little anal (teehee) but I would rather be anal than make a life threatening mistake! Keep up the good work!

Oh, my gosh, where to begin? I'm very lucky that I almost made a terrible med error my first year of nursing - I drew up epi instead of inderal to give iv push to a patient in svt (this was way back in 1974)...would have killed the person if I hadn't realized what I had done before I gave it. This taught me very clearly that even I can make a mistake (I'm kidding here guys) and I am very careful when giving meds.

One thing has helped me. I have a few rules that I never deviate from:

1. I never give medication that someone else has drawn up (even if I see them draw it up - they can give it). Same thing goes for po meds unless they're still in their little labeled pack.

2. I never have more than one syringe in my hand unless they are both labeled. Yeah, I think I can remember that the phenergan is in this one and the saline is in that one, but then the phone rings or another patient vomits and I lose my train of thought...

3. When I get that funny gut feeling, I double check and then double check again. There are some things which should sound the alarm (like that patient saying "that looks like a lot of medicine in that syringe") or when it takes 20 vials of something to get the proper amount of medicine.

4. I always ask allergies before I give the patient the medicine cup or give an injection. I can't tell y'all how many times a patient tells me they have no allergies when I triage them then right before I give them the shot, they say, "no, no allergies other than penicillin".

5. This is a gut feeling one too. If the doc says to give something I'm unsure or uncomfortable about, I double check, make sure it's in writing and double check again. I won't give anything that I know is wrong - like inderal 80mg iv - the resident swore up and down it would be okay. Then wouldn't give it himself when I refused to give it.

6. I save med containers. I look at the label before I break it open, as I draw it up, after I draw it up and then after I give it. Compulsive I know, but better to know you screwed up as soon as possible.

These rules have helped me avoid many med errors, but not all. I have noticed that most medicine errors are communication errors though. I thought the doc said talwin, he swears he said tylenol #3. It helps if you can have everything in writing first. Since I work in the ER it's not always possible.

My worst error wasn't a medication error. I took care of a 17 yo boy who died in the ER during a terrible asthma attack. The doctor was in a room with all of the family telling him what had happened. Two family members came down the hall from that direction asking me if they could see "Paul". I said of course, and went with them to the room. As I took them in, one of them said, "Oh, my god, is he..." and I interrupted and hussled them out of the room and back to where the rest of the family had gathered. I really thought they knew about the death and wanted to see his body. I felt awful, but these people were actually very understanding.

It's a difficult job we've all chosen.

[NurseFirst]

I like that one.....Did I kill Him.

Here in Dutchess County, NY we do NOT have to check insulin with another nurse. I graduate in May 2005 and I have given insulin plenty of time and never heard of that rule. Also I work at a hospital where I have never seen the nurses double checking insulin.

MrsStraty

:balloons: ADN grad in 11 weeks!

I always like that extra check. One time, however, both I and the RN I was working with read the glucose meter upside down (I had double-checked because it was lower than his usual readings)--we read 112 and it was 211. I discovered it because this particular glucometer had to be returned to its station where it would input the glucose read, time, etc. into a computer, and I had to turn it around. We've worked in other hospitals with glucometers which did not have a cradle where it was to be returned.

NurseFirst

[Schmoo1022]

We were taught to double check insulins...but who do you check with when you are the only nurse in the building?

Has anyone had a serious error from the Pharmacy and not noticed?

[MamaTheNurse, BSN, RN]

In the US we have to have insulin that we pull up double checked by other RN and then signed off. We do the same with IV heparin, IV digoxin, and IV lopressor.

at my hospital too - also, when initiating PCA's.......

we also found that having pre-printed/fill in the blank/check the box orders for insulin, it has helped on our insulin med errors - it is no longer the number 1 med error med

[curleysue]

These posts about med errors are seriously freaking me out. I have only read one page (most recent posts) and I am horrified. I know med errors occur quite frequently in fact as a patient I had a nurse give me 150mg IV demerol when it was written as 150mg IM. WOW that was really interesting. I do have a high tolerance for pain meds but that was a little too much. They never had to give me narcan or anything (thank god) but I will say my pain was cured for about 6 hours.

But honestly, this is making me think. I am in my senior year of nursing and I think these stories should be told at school! I think it would also freak some people out to be extra extra careful.

I cannot think how bad it would be to actually harm or kill someone cause you read a label wrong or didn't check the order with another RN. I just can image the gut wrenching feeling, kinda like when you do something wrong (like getting pulled over for speeding, or something like that) but it would be ten times worse!! :uhoh21:

Wow, thanks for these stories and I am sorry a lot of you had to learn the hard way about re-checking. I think it is so much better to be anal about medications. I know I will! Curleysue :stone

[stidget99]

My worst mistake happened just about 2 months ago....a colleague's pt became unresponsive. After a short period of time, it was determined that the pt's glucose was 25. While her primary nurse went to call the doc.....I went to the Pyxis and grabbed an amp of dextrose. My colleague rec'd the TO and we pushed it. The pt did not immediately respond so we went to push another amp. By that time the doc was on the floor. He saw me drawing up the dextrose. Unfortunately, I pulled sodium bicarb instead of dextrose both times. I was horrified! The doc called for the crash cart and used the prefilled dextrose syringes. The pt's BP bottomed out, and her resp ceased. We coded her and brought her back. She was then transferred to ICU. I felt just horrible about the whole situation. I tried quitting the next day but the manager and director of the unit encouraged me to come in an talk to them. I did and am still working the unit. However, I went thru several days where I didn't work. I couldn't bring myself to work. I broke the cardinal rule of medication administration. I did not triple check the med. I didn't feel competent to work the floor. I didn't feel that my colleagues would be comfortable working w/ me. I didn't think that the doc would/could trust me/my nursing skill ever again.

Well, I have since gone back to working the floor. The memory of that whole night still haunts me. The pt eventually expired but not because of my error but because she was septic secondary to numerous decubiti. The pt's family sent the nurses who "saved" their mom the nite she became so sick a thank you card. I don't believe that I was deserving to be included but I was. I am still working my way thru this whole situation. I understand what ppl tell me...I am human and humans make mistakes. The best you can do is learn from your mistakes to become a better nurse and continue on w/ your practice. So that is what I am trying to do.

[NurseyBaby'05, BSN, RN]

An instructor told us that a co-worker kept a pt's nitro paste on his bedside table and the visually impaired patient mistook it for toothpaste!!!!

[curleysue]

I am still reading through all these posts and like I said before, its definetely teaching me A LOT about how crucial it is to recheck med orders and all the medication steps over and over. Wow. This is an excellent thread. Honestly.

Anyways, I wondered after reading some posts that I know mistakes happen to every nurse no matter how careful they are it seems like it will always happen some time. But I questioned, do you guys think that because nurses these days have more patients because of short staffed units that the stress and constant running behind, or just plain being overwhelmed, doesn't that contribute to a higher incidence of med errors?

That thought popped into my head after reading a couple pages. I know its not the number one excuse that med errors are made but I definetely question that it has a major inpact on incidence. Do you guys think so?

Curleysue

[ikimiwi]

In nursing for 30 years, once set the heparin to run at 100cc/hr instead of 10, ran only 30 min, no harm done, but I got very pale....also some how I got 2" of nitropaste stuck on the back of my arm, didnt notice, but I dropped like a stone after wondering why I got such a sudden headache. What I feel the worst about was a few years ago we had a man come in DOA. Some other people came in with him, I was asking the ? about family and such, They just left the Ed. I waited about 2 hours got the mans old record found a wife listed as next of kin, called the number, a female amswered, I asked if the was,Ann, (I will never forget the name) I did the usual, he has been injured adn you need to come to the er as soon as possible, she starts getting very upset and screaming, is he dead,is he dead over and over. I had to say yes , I'm so sorry. She hangs up.So now i am about to call the police when I get another call, from one of the people who came in with him , screaming at me why did I tell her this over the phone? Well turns out I spoke to his 17 year old daughter,not his wife who unfortunatly died a few months ago. The people who came with him had gone to tell her in person, but didnt bother to tell me that was what they were doing.The home was also only 15 min from hosp,they didnt know how to tell her so they stopped somewher to discuss it.

It was just a giant mess of noncommunication, I still feel bad when I think about it. I just dont know why they didnt tell anyone theywere leaving and what they were doing.What pain that child had.

[pediatriclpn]

This one haunts me to this day. And will for the rest of my life. I was working agency at a home for MR children. Had a young lady, very active, with a trach. I worked nights, and in the am did care to get the children ready for the day. The regular routine for the regular staff was to put her back in her crib after am care so she could rest more, and/or keep her contained while doing care for others. There isn't enough staff to keep watch at 5am. Most of the time she would bounce in her crib until day staff got her out. So everyone would take the apnea monitor off, and the pulse ox probe off, and leave them off after am care, because the bouncing would make them continually alarm. No one told me the reason they took them off, they just told me that is what we do. Being agency I didn't want to buck the system, learned my lesson the hard way. Giving report to oncoming shift, CNA comes running, child is not breathing, pulled out her trach, run to check, she is in cardiac arrest. Trach reinsterted, 911 called, MD called. Epi down trach, CPR, O2, sent to hospital. Too much time without O2, severe brain damage, now needs a vent, and is a vegetable. It still breaks my heart. I learned to NEVER take off the apnea monitor from a trached child, especially when they are out of my line of sight.

[Aneroo, LPN]

Is it always the nurse's fault when an IV infiltrates? I am a student, and just two weeks ago I was giving an antibiotic IV to a guy, my instructor was right there with me. I flushed it with saline first, which went in fine, so I started the IV and went to get the linen to change his bed with. I came back, and it had infiltrated. I shut the pump off immediately and called the IV team. About 15 cc had gone in. I didn't think this was my fault, but now after reading your posts, I am not sure.

No, sometimes veins just cannot handle it, esp with IBPB... the antibiotic could have been very irritating to the vein itself. You did the right thing. You kept check on your patient, and as long as you documented everything, you're fine. -Andrea