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.

[vanillaskye]

My very first nursing job was in an allergist's office. A client had come in for a second round of tests, having previously having skin tests on the forearm. The second round of tests were done intradermally in the upper arms. There was nothing in the first set of tests that indicated any major allergies. The office assistant told me to hold off on doing the second tests because the Dr. wasn't in the office, but the nurse orienting me told me to go ahead and proceed because as long as the Dr. was in the building it was OK. I was a little less than halfway through testing when the patient started saying that she didn't feel right. She coudn't tell me anything specific. I did two more injections, then realized that she was probably starting to have a reaction. I stopped testing and called in the nurse that was orienting me, she said "Get out of here, I should've known something like this would happen!" The office assistant paged the Dr. I went and drew up the Benadryl and steroids. The patient was ok, thank god. But the nurse orienting me lied, denying that she told me to proceed with the testing. Needless to say, I quit that job shortly after all of this happened.

[sleepless in norman]

By far, my worst mistake was comming to OKLAHOMA to practice nursing, I've worked in 5 other states and never had any problems, with employers or coworkers, I come to OKLAHOMA and my license is suspended and I'm on the OIG Exclusion list for a Lortab addiction that had nothing to do with my profession, meaning no diversion. Good Luck. 's with wolves.

[bth44]

I've always heard that it's not the case of "if" you ever make a med error, it's the case of "when" you make it. And it's always that one time you didn't triple check because you were really busy, felt you were behind, etc. If any nurse out there tells you they've never made a med error, they're lying. Nobody's perfect. The first (and only so far...knock on wood) med error I made was grabbing a bottle of Vanco and hanging it on the wrong patient. The only difference between the two bottles was that one of the doses were just slightly higher than the other (one was 700 mg and the other was 750 mg or something like that). I got a weird feeling immediately after I left the room. I went back after it had been infusing for about three minutes to double check the bottle (as I should have done BEFORE I hung it...gosh) and hello: wrong name and dose on the bottle. I stopped immediately and sought help from my charge nurse. I was very lucky in that situation, and I realize that I could have hung a completely wrong drug, which could have results in something horrible. I know you'll still worry about making med errors regardless of what we all may tell you on the site and especially after me telling you scary stories, but try not to worry too much. I am pleased to hear that you have a fear of making a med error; it shows me that you take being a nurse seriously, and that you care. Having that caution in the back of your mind at all times, keeping your guard up like that is good trait for a nurse to have. Believe me, if you do your five rights, three times, every time, you will catch potential med errors. :)

[FNimuaeMae]

I've only been working ICU since last July. Had a patient being discharged to another facility, and was trying to get all the paperwork in order as he had been with us for almost 3 months and it was a complicated case. Trached, occasionally on a vent, flow-by trials. He called me in, was trying to communicate while on his trial so I put his passey muir talking valve on, left it on and hurried along on my busy way. A while later I am working on the paperwork, looking at the monitors, and his HR was in the 30's and 40's where it HAD been in the 80's. I go check him out....unresponsive to shaking...call the MD in while the team is still on rounds. We get the atropine out...RT comes in and says "WHO PUT THE VALVE ON!!??!?!?".

My fault. Learned something new....didn't know you had to deflate the trach cuff with the talking valves, as usually when I had seen him wearing it, someone else had put it on correctly. Will NEVER do that again.

And talk about being hysterically upset afterwards... the other day was NOT a good day.

But everyone was very kind, understanding and supportive. I have such great coworkers... and supervisors.

[FNimuaeMae]

The patient was fine afterwards and still got transferred that morning.

[hollyster]

The error that haunts me happened while I was in nsg school. I was working fire/rescue an decided to become a RN.

On my way home a young woman ran out into the street. The car in front of me hit her. I grabbed my medic bag and went to assess the pt. The pt had a head wound and an open fracture of her right tibia and was bleeding profusely. I gloved up before touching her. As I was gloving, a woman arrived on the scene and stated that she was a nurse. She started to apply pressure to the leg wound. I told her to get some gloves out of my bag but she just looked at me and said "this is a child." By the time the ambulance arrived the I managed to get a c-collar on her and fully assess her. I gave report to the medic and they transported the girl.

The next day I went in for pediatric clinicals and by chance the young woman was assigned to me. While getting report I was told that the pt was MVA and HIV+. When I walked into the room I realized who she was. I felt sick. All that I could think of was the nurse that had been holding her leg wound. I did not get her name or know anything about her.

But it reinforced my assume everyone has something contagious attitude.

[Labrys]

my biggest mistake was...going to nursing school :rotfl: just kidding

Honestly, I gotta say after reading some of this, I'm really starting to reconsider my choice...I am planning on going to nursing school next fall. More and more I am thinking radiology is a better idea. :uhoh21:

[skemergirl]

My worst "med error" was when I first started in the Pediartic ICU. We were really busy and I had 2 pts on q3h bolus feeds of MBM (maternal breast milk). This needs to be double checked with 2 RN's (or a care partner or a parent). This should be done at the bedside but because we were busy I caught someone in the hall & said this is for so & so in room 9. Well, I proceeded into room 6 and hung the MBM. Yep, wrong patient and YUCK!!. We had to have the mom for room 9 and the patient in room 6 do HIV tests! Breast milk is treated as a narcotic for the double checks because it is a body fluid. I ALWAYS have the co-checker come to the bedside and check the name band since then.

[MrsWampthang, BSN, RN]

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[PicklesRN, RN]

I did see a doctor kill someone once , it was really awful because I had begged that doc not to give that drug because a week before he had nearly died from it. ...

I was working ICU one night and the resident ordered Augmentin for a patient. It came up in liquid form and the resident was going to give it IV! Yes, IV! I heard the nurse all but yelling not to give it and he was the type with the attitude he was the doc, the nurse was but a lowly 'gofer' ... you know, go for this and go for that.

She kept begging him not to give it, she said it was PO only. He insisted it wasn't, it was IV. Finally the nurse ran out to get the clinical RPh and they ran back to the room just as the resident had finished giving Augmentin IV. The RPh asked what the h*ll he was doing?

The RPh went on to ask when he has ever known Augmentin to be made for IV use and the nurse chimed in to add ... and since when do IV drugs come in Bubble Gum flavor!

Finally, the resident caught on and realized what he had done. Amazingly, the patient was fine and suffered no problems becuase of it.

I fully understand human error will happen. We are all human and we will ALL make mistakes. But it is nothing but stupidity and ego when someone is begging and demanding you stop and think about what you are doing and you ignore the huge issue the nurse was making out of this. When someone is that adamant there is a problem, you don't just ignore her, you stop and think.

[PicklesRN, RN]

I am sure if I rack my brain I can come up with a mistake I have made recently, but my biggest mistakes have been not being assertative enough when I KNEW there was something wrong with the patient and no one would listen.

I have one of those. It was about 15 years ago and to this day I feel horrible about it and it still haunts me. I knew my patient was not doing well on her meds, I knew she was pretty darn stable and doing well and suddenly some bright doc decided she needed mega treatment for mild asthma. She was Paranoid Schiz so she was already on a slew of psych meds and the doc ordered a huge amount of meds for mild asthma.

If you looked at her MAR you can't really say the drugs were not okay to be given together but how many studies have been done with those specific 21 different drugs? Polypharmacy at its best.

Within 24 hours something was very wrong. I called the doc and he said she was fine. I told him she wasn't, he reminded me he was the doc. The next morning she was dead. Just as I came into work she was coding. Her face was the size of a small watermelon. I *knew* something was wrong but I didn't push hard enough. Her symptoms were not really specific the previous day, it was one of those things that I knew her well enough to know something was very wrong. Vitals were fine, she had no complaints... but she was having a reaction to one or more of the new drugs.

I still think of her often. I regret that I didn't push until someone listened to me. I could have easily pushed the issue but I didn't.

For me the lesson was to listen to that little voice in the back of my head, it rarely leads me in the wrong direction.

[Daytonite, BSN, RN]

When I was a head nurse I had to deal with two different medication errors that I would like to share with you all.

The first was done by a young RN who had been out of school almost a year. A doctor had written an order for Morphine Elixir xxmg prn pain. He did not write the route. He assumed the nurses would know that the Elixir would be given orally. This nurse did not. Nor did she question the order. Morphine Elixir is a beautiful bright blue color. I cannot think of any IV medication that is blue. However, this young nurse drew the amount needed into a syringe and injected it into the patient's IV. It was then that the nurse began to question her decision to inject this medication IV. The patient suffered no adverse effect, but we did some serious counseling with this nurse and had her complete a medication administration program with the education nurses and put her on probation.

The second incident occurred with a graduate nurse. Her preceptor watched in horror as she drew up a dosage of a patient's insulin in a 3cc syringe with a 1 inch needle on it. The preceptor watched quietly. As the new nurse was capping the needle, her preceptor starting asking her if she felt that she had the correct dose and had prepared it correctly. Again, the preceptor was horrified when the nurses' response was positive and that she was ready the give the Insulin. At that point, the preceptor stopped her. Several other incidents just as horrifying occurred over the next few weeks and this lady was, unfortunately, terminated. We were informed that she had failed her state board exam which may have been a blessing for any future patients. I still wonder how she was ever able to pass her nursing courses.