Your Worst Mistake

Nurses General Nursing

Published

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.

Specializes in Geriatrics and Quality Improvement,.

It is a real shame that you gave up on nursing, on yourself. So many these days wont admit their errors for fear of reprimand. I worked with a nurse who cut the Dopamine drip in half because she didnt want to run down to pharmacy to get a new bag and she was running low. The gentlemen died 5 minutes into the next shift. That nurse still holds her licence. You my fellow nurse would be a shining example of aptitude. Transcription errors, 1 mg instead of .5 mg of meds given. And nurses saying..arent all beta-blockers the same? Whats the difference between 0.25% and 0.3%? In 14 years, any nurse can tell you, errors are made. The fact is you didnt do any permanent damage to that person, and were responsible enough to make the right judgement call for yourself and for the patient. You are to be commended for that much at least. Im sure others in nursing have lost something because they did not have you to work with. :nurse:

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.
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 hope you will change your mind. You sound like a wonderful, caring nurse. I know some who would not have admitted to their mistake as you did. Please reconsider.We need nurses like you.

Eeyore

Specializes in Me Surge.
actually, my worst mistake to date was pretty similar to yours, mwcia12... it was my 1st semester of my RN course and i was looking after an elderly gentleman who was due for a transfusion... we were waiting on the blood to come up from the lab and the hospital's policy was that students could not hang blood, so i went to lunch... while i was at lunch, though, the blood arrived and the RN i was working under had hung it... but as soon as she had hung it, she went to lunch as well and left the RPN in charge of monitoring the patient for a transfusion reaction...

so, i get back from lunch about 30 minutes later and i asked the RPN for report and she said that she had checked his vitals and everything appeared to be fine... so i go into the room and do the classic mistake of focusing on the lines/machines hooked up to the patient instead of really assessing him... i stupidly overlooked assessing the site, but i asked the patient if he had any complaints or pain and he said no...

well, 10 minutes later, the patient's son comes out to the desk where i was charting to find me... he said the patient's arm was really hurting and it looked bruised... and my first thought was "crap, it infiltrated!"... sure enough, it had... the poor man had about half a unit of blood in his tiny little arm... it just looked horrible... so i stopped the infusion, elevated the patient's arm on a pillow and called my clinical instructor... my instructor was pretty cool about it and we applied warm compresses (as per hospital policy) to the site and restarted the blood in his other arm... we explained everything to the patient and his family and they were really understanding about it all... i felt SO bad...

to make matters worse, the RPN totally flipped on me saying that i was negligent because i was responsible for the blood, not her... i think, in hindsight, that she was worried that the mistake would come back on her because she was responsible for monitoring it while the RN was away, and the half a unit would have started infiltrating before the last 10 minutes that i returned to the floor and checked the patient... but, of course, being a student i felt like i had screwed up royally... i think that was the only time i ever contemplated quitting the program...

anyway, i feel pretty lucky that it was my biggest mistake to date because there definitely are a lot worse things that could happen... but you can bet to this day, when i do an assessment, i start with the patient and work my way back to their lines rather than focusing on the pumps anymore!

beth :p

Actually, the RN responsible for the patient is a fault. I would never hang a unit of blood and then go to lunch. If I had to have lunch then I would have waited until I returned to start the blood. I don't know where you are, but as far as I know only an RN can hang and monitor a blood infusion. Yes, the first thing you should look at is the patient. Common policy is for the RN to remain at the bedside for the first 15-30 minutes of the transfusion to monitor for transfusion reaction.

Specializes in Me Surge.
my biggest mistake was second guessing my first thought and taking to long to make the right decision. at the time i was a ...medication aide in a nursing home and that night i was in the med room auditing the carts for reorders. when i came out i saw ems and i had heard nothing inthe med room. soo i went to go see what was going on and found that a res had coded.emts were doing cpr to res and the nurse in charge was standing at the door to room. i approached her to find out what had happened and she said that the aide just found her that way. i asked her if she had initiated cpr and she told me hell no i aint puttin my mouth on that thing. and a few minutes later i had asked the cna what happened and she told me what she found and that when she called the nurse she called 911 and that she just stood there lookin at pt and when the cop that was first to arrive on scene he did the same thing .the res never recieved cpr until ems arrived .had i heard anything i wouldve done it myself but what the problem is that i didnt report it right away to administrative staff as i figured what good would it do it was my word against hers. and at the time i was in nursing school so the next day when i went to class i wanted to get my teachers opinion about the situation so i mentioned the scenario to the class leaving names out.and the next day i got called into the office at work as they said that i broke pt confidentiality by saying what happened and mentioning names which i didnt what happened was that one of my classmates worked at the hospital that the patient was taken to and this was small town so was easy to find out specifics and she called my job saying i broke pt confidentiality.so when i went inthere i explained exactly what happened the night of the code and why i was talking bout the incident and that i hadnt mentioned any names.of course they didnt believe me so i called my teacher and she verified that i never stated a name.anyways the place let me go saying that i endangered the pts life by not telling administrative staff right away(i was getting ready to quit anyways so that didnt bother me)but what bothered me the most was that even after all that i had told them that happened and they had statements from cnas and police and emts the nurse was still working there. some of the cnas tried to cover up for her but all the other peoples statements coincided with mine. sooo my point is to the whole horrible ordeal is report anything and everything even the minute stuff cause in the end it will come back and bite u in the butt.by the way the pt did die and she was a full code.:crying2: ps sorry bout the spelling and such just tend to get lazy when ur on the comp.

She should have lost her license. To stand by and not initiate CDPR on a full code is inexcusable. By the way, wasn't there a bag/mask to bag the patient with.

Don't they have ambu bags in nursing homes? I'm about to transition from med-surg to a nursing home and once I'm there, if they don't have an ambu bag, I'll personally go to a med supply store and buy one. :angryfire

So far my mistakes have not yet been serious, I know I will have one though, everyone does. Just the other day I was to give 140 mg IV of a steroid to a post op pt. This steroid was to cover her does for the day since she couldn't take her po meds (she was on high doses of steroids). Well this pt was ill and nauseous so there were many IV pushes to give until I found the right combination and when the steroid was due I brought it in and gave it. The pt was finally asleep after vomiting/being in pain so I didn't announce what I was giving and what it was for like I normally do.

Two hours later she was awake and asking for more nausea medication. She casually mentioned perhaps she was nauseous because of "all those pills she took"!!! I asked her which ones and she rattled off her list of daily meds her partner had helpfully brought from home - including the steroids. It's terrible having to tell your charge nurse and the pt you made an error and to write up an incident report but luckily pt was very understanding. I will never again give a med without reiterating what I am giving or discussing it with pt ahead of time!!!

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.

Specializes in NICU.

I caught holy heck today for letting my knee touch the floor when I crouched down to do, um, something I don't actually understand to a PEG tube. Thread it through the pump, I think? Anyway, the RN made me go home at lunch and change my pants because my knee touched the floor.

Specializes in Pediatrics, Nursing Education.
I caught holy heck today for letting my knee touch the floor when I crouched down to do, um, something I don't actually understand to a PEG tube. Thread it through the pump, I think? Anyway, the RN made me go home at lunch and change my pants because my knee touched the floor.

Uh oh. In peds, I do that on a daily basis! I try not to rub my knees against my patients tho. Hospital floors are dirty... but it is hard when you are unsteady like me!

My worst mistake ...

I work in the OR and occasionally, our patients have local anesthesia for their procedures. I made the mistake of not posting the "Patient is awake" sign on the door while the patient is having a bilateral orchiectomy. One of my friends came to my room to say hi. She looked around to see what case I was doing. Then all of a sudden, she blurted out, "Is it OK for men to live without their balls???" The room got deadly silent and after I whispered to my friend that my patient is awake, she quickly slipped out of the OR.

I know this is old, but I just read it and all I can say is HOLY CRAP!!! :stone

It's been said before, but as new grad, it's so important to hear these things, so thank you all for sharing. It has certainly opened my eyes, knowing it can easily happen to me. Seems like there are 2 kinds of nurses: one who has made an error and one who will. (shudder)

Once upon a time, in the icu, I was taking care of a patient who was receiving iv fluids and Diprivan. Sometime, during the night, I went in to hang a dose of iv antibiotic, which I piggybacked into the iv fluids. I dialed the amount and rate of the antibiotic, pushed the start button, and left the room. About 10 minutes later, I looked up at the monitor which informed me that the arterial line bp reading was like, in the 70's/30's. Not good. I ran into the room assessed my patient and the situation. The source of the low bp quickly revealed itself. I had dialed the rate of administration for the antibiotic into the channel that was running the Diprivan!!!! I wanted to vomit, I was so horrified at what I had done. Fortunately, the problem was easily reversed by turning off the Diprivan, and within 30 minutes, the patient's bp was fine. Lesson learned: to this day I don't run Diprivan and fluids on the same pump!

Don't they have ambu bags in nursing homes? I'm about to transition from med-surg to a nursing home and once I'm there, if they don't have an ambu bag, I'll personally go to a med supply store and buy one. :angryfire

Get a pocket sized face shield. I have one and it never leaves my side. Just in case.

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