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 NICN.
Again, id like to emphasize the check and recheck and triple check... that way our chance of commiting a mistake will be put in mitigation...

Are you practicing as a nurse or are you a student?

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Specializes in NICN.
I remember a nursing instructor I had who once siad that any nurse who has been practicing for several years and says she's never made a med error is lying.

My instructors have said that if you never have a med error you are falsifing (sp?) information on a chart. I have to agree...we are not robots who can do everything absolutely perfect. The only time I believe a true mistake has been made is when someone doesn't learn from their mistakes and the mistakes made by others.

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Nobody's perfect! or so they say... But i honestly believe that in our profession, in which evry action we take has bearing on the safety of life of another individual - THERE SHOULD BE NO ROOM FOR ERROR:nono: ... That is why it is important to check and recheck... I really hope you learned from it, and i hope that next time, you will learn without putting the client's safety at risk..

LOL... oh boy are you a newbie! Darl'en, you have a lot of learning to do regarding human nature. Humans are not perfect beings and the first time you make a mistake, AND YOU WILL, I hope you give up the crappy attitude and learn to take care of the mistake. THAT is the key.

Like it or not, we ALL make errors and that includes you. That's reality, that is how life is. Some make mistakes all the time and those are the folks that need to find a new profession. But everyone (again, including YOU) makes mistakes.

However, when you find that ideal world where everyone is perfect and nobody makes mistakes, be sure to let us know, k? In the meantime...

BWAHAHAHAHAHAHAHAHAHAHAHAHA

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Are you practicing as a nurse or are you a student?

Isn't it obvious?? :rotfl:

Sorry... back to our regularly scheduled program...

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Well I have a few some not as a nurse

I just started working with wheelchairs transferring a lady to chair via stand pivot (she had no ability to stand/catch herself) Iplaced her in her chair forgot to lock her brakes, go behind her to pull her up so falls forward on the floor breaking her nose. I felt to bad. That was 10yrs ago.

Another patient I transferred from bed to wheelchair. Somehow her arm got tangled with my clothes (we dont wear uniforms) and placing her in her wheelchair I broke her elbow. That was last Easter. since then PT changed her orders to a boom lift.

BUT MY WORST: I work in a group home for disabled. There is the RN assigned to 5 homes. I am one of 3 (i think) LPN stationed in a group home. Basically I am her eyes and ears, she cant be everywhere. So one lady entered the hospital and we got a respite at the same time. I put the lady in the hospital medication in another locked drawer that only the house supervisor had keys to to make room for the respite 19meds. Now during the last couple years the supervisor we go in the med cabinet from time to time and any expired meds would dump them in the supervisor drawer to get rid of them (bottle and all) I had known they were in there but never really thought about it as my supervisor is a grade 14 im a 10. Well our new team leader finds out about these meds, huge investigation occurs I get dragged in. Im thinking im so screwed. This occured when a new house manager took over. I get brought up on charges of improper storage of medication. I explain that no we dont keep meds, but the patient in the hospital ect.. and I kept her meds incase she return home on a sunday. THese pills everyone of the 13 staff in the house Knew they were there. I get a formal couseling out of it. The supervior told staff to lie and say they had no knowledge of the pills. (2 staff very close friends of mine told me they were told to lie) Not sure how close they are as they did lie. I brought this up nothing happened to anyone but myself. I was looking at a huge fine but got a formal counciling in my record for 2yrs. It was a lesson learned :Dont trust noone. But also if i had knowledge i should of done something and didnt. It was the hardest 3 months of my nursing career. And no Im still not over it as the judgement came down in September.

"In group homes nurses have been notoriously known for stock piling meds incase someone runs out, you just got caught." .. words from the supervisor who turned it in.. NICE!!

*** I trust no one now!***

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Specializes in Burn/Trauma PCU.
nobody's perfect! or so they say... but i honestly believe that in our profession, in which evry action we take has bearing on the safety of life of another individual - there should be no room for error:nono: ... that is why it is important to check and recheck... i really hope you learned from it, and i hope that next time, you will learn without putting the client's safety at risk..

wow. good luck with that "no room for error" thing when you're an rn. chastising others for events that they are probably having a hard time forgiving themselves for shows a lack of compassion and grace, imho, and those are two essential qualities to be a nurse. don't be the one to throw the first stone.

back in my singing days, my wise vocal instructor always told me that it was never a question of "if" i would make a mistake in performance, it was "when"... and how i recovered from it. while i realize that singing an aria and caring for a critically ill patient are two vastly different worlds - no one's life ever depended on whether i hit that high c or not, though at the time, i thought mine did :rolleyes: - i believe the principle to be the same: it is naivete (and lack of preparedness) to believe you will never, ever make a mistake, but it is wisdom to know that you will have a mistake sometime, even while taking every possible precaution, and to recover well from it (not cover it up, but own up to it and immediately work to rectify the situation).

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Specializes in NICN.
wow. good luck with that "no room for error" thing when you're an rn. chastising others for events that they are probably having a hard time forgiving themselves for shows a lack of compassion and grace, imho, and those are two essential qualities to be a nurse. don't be the one to throw the first stone.

back in my singing days, my wise vocal instructor always told me that it was never a question of "if" i would make a mistake in performance, it was "when"... and how i recovered from it. while i realize that singing an aria and caring for a critically ill patient are two vastly different worlds - no one's life ever depended on whether i hit that high c or not, though at the time, i thought mine did :rolleyes: - i believe the principle to be the same: it is naivete (and lack of preparedness) to believe you will never, ever make a mistake, but it is wisdom to know that you will have a mistake sometime, even while taking every possible precaution, and to recover well from it (not cover it up, but own up to it and immediately work to rectify the situation).

well said!!!

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wow. good luck with that "no room for error" thing when you're an rn. chastising others for events that they are probably having a hard time forgiving themselves for shows a lack of compassion and grace, imho, and those are two essential qualities to be a nurse. don't be the one to throw the first stone.

back in my singing days, my wise vocal instructor always told me that it was never a question of "if" i would make a mistake in performance, it was "when"... and how i recovered from it. while i realize that singing an aria and caring for a critically ill patient are two vastly different worlds - no one's life ever depended on whether i hit that high c or not, though at the time, i thought mine did :rolleyes: - i believe the principle to be the same: it is naivete (and lack of preparedness) to believe you will never, ever make a mistake, but it is wisdom to know that you will have a mistake sometime, even while taking every possible precaution, and to recover well from it (not cover it up, but own up to it and immediately work to rectify the situation).

very well said... although we are talking to someone named "hot male," he may have confused this with an online dating service :rolleyes:

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Very well said... although we are talking to someone named "hot male," he may have confused this with an online dating service :rolleyes:

A bit of an attitude issue, don't you think?

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A bit of an attitude issue, don't you think?

To say the least :p

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my error is going to sound like no biggie compared to some other people's, but it'll be a cold day in hell when i forget the lesson learned..

had a patient who was a not-so-compliant diabetic, QID BSLs, sliding scale actrapid and nocte protophane. took her BSL at 2030, then took her chart to the fridge to get her insulin. We were short staffed, so the supervisor was helping out on our ward, and i grabbed her to check the insulin and chart with me (policy at my hospital). while drawing up, talked about whether you draw up clear or cloudy insulin first, then went off to the bedside to dive the insulin. told the patient i had her insulin, and she uttered the time-honoured words 'there's a lot in there, isn't there?' to which i explained that this was because i had both doses in the one syringe. gave the needle, went on with my business, went home.

overnight, i started thinking about it, and thinking 'was that a QID sliding scale or TDS?', but comforted myself that the very experienced supervisor had checked with me, so even if i'd made an error, she'd have looked at the chart too and would have noticed it. relieved, i went to sleep.

next morning, had an early shift and was assigned the same patients as the night before. checked this lady's BSL, and once again went to the fridge with her chart and the nurse i was working with. opened her chart, and there in front of me was her TDS actrapid sliding scale, with my extra dose neatly signed for, complete with 20 u/s written underneath so people could see what dose had been given.

started in with a chorus of uh-ohs, and pointed my mistake out to the nurse i was working with. she looked around, made sure no-one was listening, then asked me what the pt's BSL was. told her it was 5.something, and she then proceeded to tell me not to say anything, as the lady was clearly fine and it wasn't worth getting myself in trouble when probably no-one would notice. she even recommended that i cross out my signature on the chart and write error on it, as if i'd written it in, realised my mistake and not given it.

i was very keen not to get into trouble, and was so embarrassed that i'd screwed up just when i was starting to find my feet, but deep down i knew i'd screwed up and it'd bother me till i dobbed myself in. luckily, the cnm was away that day (she made me a little bit nervous), and the nurse in charge was possibly the kindest person on the face of this earth. i grabbed her in the hallway, and got as far as 'can i talk to you for a sec' before bursting into floods of tears.

after calming me down by telling me about times she's screwed up (with the help of an orderly who chipped in by telling me about his army days when he screwed up in a huge way in front of his biggest, meanest boss), she got the whole story, told me i'd dome the right thing telling her, reassured me that the patient would be fine and that these things happen, and helped me fill out an incident form, which i don't think she even forwarded to the cnm, but which made me feel miles better.

i got to go home that day rattled but feeling that i did the right thing, and i certainly learned my lesson. your eyes may think they see something on a chart, but then, sometimes people's eyes think they see dancing babies!

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The error another nurse told me about when I was crying on the BMT floor as a new nurse will always stick in my brain...

She was transfusing some blood, and it just wouldn't tranfuse at all. She slowed and slowed the rate, but no go. Finally she put a blood pressure cuff on the bag to force it in.

Well, the reason it wouldn't go in is that it wasn't hooked up right to the IV. So the connection fails, and blood starts spraying all over the walls, all over the patient, all over her. It's everywhere. The DON was walking by. She came in to find the nurse repeatedly wiping down one spot of a bedrail over and over again with a cloth, and blood flying around the room.

They finally clean everything up, including the blood-soaked patient who is an elderly Japanese man, sitting calmly throughout the whole thing.

The next day she walked into his room, and he smiled and said in a thick accent "Ah! The nurse with the blood. No blood today."

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