Your Worst Mistake

LoriAlabamaRN · Dec 27, 2005

I am so glad to have this thread... it has really given me some "heads up" advice as far as what can and cannot be allowed to happen and what must be watched closely. Thank you to everyone who has posted- any more?

LoriAlabamaRN · Dec 27, 2005

Sorry- duplicate post

HeadGames · Dec 27, 2005

This likely isn't my worst but it is what comes to mind. I had a patient that would cheek his meds. He was a psych patient. The doc ordered Thorazine Concentrate Liquid. At least we could have a better chance of knowing if he was taking his meds.
Regardless of what I put the concentrate in, it was amazingly bitter and beyond horrible to get down. I finally put it in milk. As usual, my schiz patient drank it down.

"...my schiz patient..." Really? Please rethink your labeling of patients. It is really demeaning :stone.

southern_rn_brat · Dec 27, 2005

I'll never forget my first one either. I was only about a month into my 1st job and had a patient ordered Augmentin. His wife was in the room as I was giving it and says "He's very allergic to pcn" I say "oh dont worry this is augmentin" and as he starts to swallow I realized what just came out of my mouth but it was too late. His last reaction to pcn had been a true anaphylactic reaction:bluecry1: . omg I started crying right then and there and I continued to cry as I called the doc, the DON and anyone else I could think of. I refused to leave his side that evening. He and his wife ended up consoling ME lol. I beat myself up over that for over 6 months until the DON had a talk with me and told me I HAD to let it go and move on. I didnt think I deserved to be a nurse.

Last Febuary I discharged a patient and made an error and put tegretol on his dc orders. About a week later his dialysis clinic called and I just so happen to be the one they talked to. They wanted to know the diagnosis we had for putting him on that for their records. The doc was in on rounds at the time and she looked thru his old chart to find out for me. She said " look at this...some IDIOT made an error on his dc orders" I rolled my eyes and said "omg who was it" and she laffed and said YOU. He had no adverse effects from it luckily since he was on dialysis. I have spent a few hours with risk management though because not long after I personally called the family and admitted my error, we got a letter from a tv lawyer:scrying:

Keysnurse2008 · Dec 27, 2005

MWCIA12,

Just learn from your mistake. Never hang blood or anything thru a pressure bag unless that patient is crashing on you.If it cant be run thru a pump at 999 / hr without alarming then there is a major problem.That IV is either infiltrated...too small for the solution - and it is going to infiltrate-it will!...or you have 2 solutions incompatibly mixed and it doesnt NEED to go in. Either way....you never need to force it in, check for blood return.No blood return= start another IV when it is blood you are trying to infuse.

A few months ago....I was asked to come look at an IV site for another nurse.This nurse had "forced" a extremely irritating solution in.When I entered the room....it was 30 minutes after her and her cohort had "squeezed" in the last drop. The patients hand was cyanotic on the palm...and you could literally watch the discoloration advance. I got physicians in to look at it,..placed a kpad on it....and assisted the nurse and physician. No matter what we did, or the physicians or the plastics team tried it didnt help. The patient died the next day bc of the initial injury she came in with......but if she hadnt....she wouldve lost the arm from the elbow down. Scared the 2 nurses involved to death...which is really good.Same as you....you will not ever want to see that sight again huh? There is a set of standards that IV therapy nurses and all nurse have to go by...I cant recall the name...but if you typed in "IV therapy guidelines" youd probably find it. Live and learn from this. How did the site look the next day?

LoriAlabamaRN · Dec 28, 2005

"...my schiz patient..." Really? Please rethink your labeling of patients. It is really demeaning :stone.

I don't think any harm or "demeaning" was meant. She was simply clarifying the patient. We can't exactly give names. I've often said "my hip patient" or something similar. It's meant as a descriptive factor, not a demeaning one.

This thread is one in which nurses are telling deeply personal situations where they have made a med error. Can we focus on that and not on petty dissections of the posts?

Bipley · Dec 28, 2005

I don't think any harm or "demeaning" was meant. She was simply clarifying the patient. We can't exactly give names. I've often said "my hip patient" or something similar. It's meant as a descriptive factor, not a demeaning one.
This thread is one in which nurses are telling deeply personal situations where they have made a med error. Can we focus on that and not on petty dissections of the posts?

Once again, we agree.

NurseNili · Jan 4, 2006

here's a few of the mistakes i have made in my illustrious nursing career: not getting enough sleep between shifts and being dead tired at work, which distorts judgment and critical thinking skills; mistaking "unit" for "cc" (read: gave wayyyyyy too much insulin iv", accidently infused an entire litre of ns into an 18 month old child, while trying to clear air from an iv pump and running it wide open to feed the saline through (new infusion pumps have helped eliminate that mistake), mistaking a bbb for v-tach, and precordial thumping someone who was awake and alert (can we say duh????), instilling "antibiotic" eye drops into an 8 year old child's eyes, only to discover that i grabbed the wrong bottle and instilled pupil dilating solution into her eyes (always remember that a red capped bottle of eye drops indicates "dilator", a helpful hint from my opthamologist), giving 10 mg of calcium chloride ivp over 30 seconds for a patient with a high k+, all the while watching the patient's rhythm go from nsr to sb to asystole, and not recognizing that this was happening, before a co-worker ran into the room and administered atropine (the patient lived, but i just about died, and now i give calcium chloride ivpb over 10 minutes), do i need to go on?

point is...you can make mistakes and still be a fabulous nurse, as long as you learn from them and never do them again. i am very fortunate to be working in a facility that has a non-punitive med error policy...they always say "it's a system error". gotta love that, but actually, it usually is, it is almost always not just one person's fault, there are usually contributing factors for pretty much every situation. my excuse? as an er nurse in an ed that sees over 200 patients per day, many with high acuities, i am always in a hurry, but taking 10 seconds to check myself for critical errors has prevented me from making more mistakes...don't let any nurse tell you that they have never made mistakes. every one of us has, to error is human, right? :devil:

Marylou1102 · Jan 4, 2006

I've been a nurse for 35 years and I've made my share of med errors and I've seen others do the same. The worst error I ever saw was made by a Doctor. I was still pretty new to nursing and had never worked in the ER or had any real experience with cardiac patients. So of course one night I get pulled to the ER where I am the only RN, and the ambulance brings in a gentleman in full cardiac arrest. In the room was the doctor, 3 EMTS (to get in the way), the LPN, the night shift nursing supervisor and me. During the code Doc asks me to get a particular cardiac medication. I don't remember what it was now. As taught I repeated the order and dose back to him which he confirmed. The supervisor was already in the alcove pulling out the meds and told me we only had half the dose needed. I thought that was odd because we had counted all the drugs when I came on and were fully stocked. I was told to go to the ancillary pharmacy and get the rest of the dose anyway. After the supervisor drew up the medication she gave me the syringe. I took it to the Doc and again repeated the med and dose. He indicated that I should give it IV push. I told him I couldn't give it so he did. The patient was not revived. About 2 days later I got a call at home from the hospital administration. They were questioning the drug and my giving it. I told them I didn't and why, and that the Doc gave it. I was really afraid that they were going to try to pin it on me. Turns out that the dose was more than 10 times what it should have been and that was what killed the poor guy. I never heard what happened to the Doc or the supervisor, if anything.

The point is never be afraid to follow your instinct, never be afraid to refuse and know your nursing protocols.

Gompers, BSN, RN · Jan 4, 2006

The supervisor was already in the alcove pulling out the meds and told me we only had half the dose needed. I thought that was odd because we had counted all the drugs when I came on and were fully stocked. I was told to go to the ancillary pharmacy and get the rest of the dose anyway.
Turns out that the dose was more than 10 times what it should have been and that was what killed the poor guy. I never heard what happened to the Doc or the supervisor, if anything.

That's a good story - always pay attention to things like that. You hear stories about that all the time - a nurse taking a bunch of vials to draw up one dose of medication when you usually would only use like half a vial per dose, etc. If you ever have to call pharmacy to get MORE of any kind of med, make a mental note to double, triple, and quadrouple check what you're giving.

I'm glad you had the doc give the med instead of doing it yourself.

LoriAlabamaRN · Jan 23, 2006

It's scary how easy insulin errors are to make! At my facility as the RN supervisor, I rarely give meds with the exception of IV pushes, but one of the LPNs here made a scary error last night... one of our doctors wrote a "u" after the insulin dose, which they aren't supposed to do because it is too easy to read as a "0" which is just what happened... 80 units instead of eight. The resident fortunately complained of feeling dizzy, was noted to be diaphoretic and cool clammy skin. CBG checked and was 38! By the grace of God she's fine, and I think everyone involved so far has learned a valuable lesson- now let's hope that doctor does!!!

GLORIAmunchkin72 · Jan 23, 2006

How high was the resident's blood sugar to start with? I assume she had to take it before she administered 80 units of insulin.

It's scary how easy insulin errors are to make! At my facility as the RN supervisor, I rarely give meds with the exception of IV pushes, but one of the LPNs here made a scary error last night... one of our doctors wrote a "u" after the insulin dose, which they aren't supposed to do because it is too easy to read as a "0" which is just what happened... 80 units instead of eight. The resident fortunately complained of feeling dizzy, was noted to be diaphoretic and cool clammy skin. CBG checked and was 38! By the grace of God she's fine, and I think everyone involved so far has learned a valuable lesson- now let's hope that doctor does!!!