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.
I made a med error very early on: as a student nurse! I was on a postpartum unit and one of my 2 pts needed a vaccination for rubella. I was in the room with Pt A and dicussed the shot with her while the nurse was present. Then I helped Pt B get into the shower (made sure she was steady on her feet since she had a C-section). The nurse came into the room and said, "don't forget to give her the rubella vaccination with your instrcutor." It was at that point I was convinced I had to give Pt B the vaccination. So, I went with my instrcutor, drew it up, looked at the MAR (the MARs were kept all in the same place--something my current unit does not do, Thank God!), discussed the 5 rights with my instructor, walked right into Pt B's room, checked her armband and asked her DOB, and gave her the vaccination. A couple minutes the later, the nurse asked me if I had given the vaccination to Pt A and I felt my heart leap out of my chest. I felt HORRIBLE. Of course we had to fill out an incident report and explain to Pt B that she was now extra-immune to rubella. My instructorwas very understanding, esp b/c she had been with me for the whole process! I kept it together on the floor, but I just cried and cried when I got home. I almost quit nursing school that day. It was a year before I felt mostly OK giving meds. I've had my license for over a month now and I triple, quadruple times check my 5 rights. I am obsessive about it. Sometimes I get that "did I give the right pt the right meds?" panic in my head, but at least it keeps me on my toes and makes me that much more careful. I never allow myself to rush, no matter how behind I am. I ALWAYS look up drugs I am not familiar with, no matter how long it takes. I was fortunate my mistake was what it was, but I truly believe it has made me a better, more vigilant nurse. Rumors in my program spread how someone had done a med error, and everyone was like, "Well, what kind of nurse are they going to be? Not a very good one." Yeah......well, at least I can admit to being human.
My worst mistake was the day i was supposed to add 130mg of quinine into 130mls of 4.3% dextrose saline via a buretrol but i ended up putting it through the wrong opening of the buretrol so the whole quinine poured out.
What really made me feel bad was how the child's mother yelled at me and the nurse in charge didn't help matters when she found out. She called me and spoke to me in such a way that i felt incompetent i felt like not resuming to work the next day.
Our supervisors always tell us nurses don't make mistakes but they forget we're human and could make mistake. I think the important thing is to learn from our mistakes and contiune our good work and not to give up. I'm glad i reported to duty the next day coz i was able to apologise to the child's mother once again.:blushkiss
My worst mistake happened about 5 years ago. I was working in a LTC on pm shift. Two med passes , 35 patients, and all that goes with working pms. There was a brittle diabetic on g tube feedings, I changed the feeding and gave him his hs meds through the tube. I thought I turned the feeding back on well... After being off for 2 days I came back to work and found that the patient was found with his feeding not running at 0130 on the next shift and had a bs of 35:eek: Needless to say he was sent to the hospital. Fortunately he came through ok. Now I triple check before leaving the room that the pump is definitely running!
My first nurse manager told me she expected me to make mistakes. WOW. Afterall we are only human. I tell my co-workers this almost daily. Still have to do all of our checks and report ourselves and others but we are not robots. I'm getting older and the brain is getting foggier.
That's fair as long as she is not allowed to screw up either.
My first nurse manager told me she expected me to make mistakes. WOW. Afterall we are only human. I tell my co-workers this almost daily. Still have to do all of our checks and report ourselves and others but we are not robots. I'm getting older and the brain is getting foggier.
This isn't a "med mistake", more just pure clumsiness. But sooo scary. I work ICU, had a 26 year old OD, super sick, all kinds of pressors going (Levophed, Vasopressin, etc), family at the bedside. I come in to check on the patient for my initial assessment. As I'm walking away to go to the other side of the bed, my foot snags on something. Oh yes. The triple lumen catheter (we call them SLICs), pulled out. And, you guessed it, no other access. And, of course, where all the pressors are going....I just about puked. My heart was racing, hands shaking, called my charge to help me out (because, in addition to needs the pressors, her sats were in the 80's, on 100% FiO2, on the vent, so I needed to deal with that as well). Ugh, makes me sick just thinking about it. But, we got her put back together quickly enough, whew.
My worst mistake was administering PO medications without first checking the patient's identification bracelet and not explaining what the medication were for. As well as, giving heparin IM instead of SQ and injecting it in the deltoid instead of the abdomen. =/
Got a trauma pt in with one IV line that was a bear for the medics to get in. I was cutting the clothes off and cut right through the IV line.
Worse: Doc established an IO in a pedi trauma pt and then asked for something. I turned around to get in and tripped over the line, which had not yet been secured. I snagged it hard enough to yank that IO right out of the tib. Doc was not happy.......
wow, this is so much like my biggest error. I did the exact same thing. Instead of pulling up 4 units, I drew up 40. Even when the pt said, "why is there so much in the needle?" it didn't click. Like you, it was much later in the day when out of the clear blue it hit me. I immediately called work, and they informed me that she had bottomed out, but was currently stable. I reported my error to the DON, but even with her reassurance, I lost a lot of confidence in myself.
My biggest scariest med error also involved insulin. When I was in nursing school doing a clinical on a telemetry floor, the nurse I was following said she didnt have time to double check my meds and for me to just give a patient his am nph insulin and send him home. So I drew up 25 units of insulin, administered it, reviewed his DC orders, and sent him home. Later, it must have been that evening becuase I had finished my clinical and went home, it hit me that I had drawn up 25 units of regular insulin instead of nph, I had mixed up clear and cloudy............I was so upset, I called the floor and the nurse told me not to worry about it. The patient was a young guy and routinely checked his own blood sugars and was probably okay. But it still scared the absolute crap outta me, and taught me a valueable lesson about having someone check your meds with you, even as an experianced nurse if you are unsure of something. I still feel guilty about it, and wonder if the pt suffered really bad effects from it, and wish I had caught it before he went home.
My biggest scariest med error also involved insulin. When I was in nursing school doing a clinical on a telemetry floor, the nurse I was following said she didnt have time to double check my meds and for me to just give a patient his am nph insulin and send him home. So I drew up 25 units of insulin, administered it, reviewed his DC orders, and sent him home. Later, it must have been that evening becuase I had finished my clinical and went home, it hit me that I had drawn up 25 units of regular insulin instead of nph, I had mixed up clear and cloudy............I was so upset, I called the floor and the nurse told me not to worry about it. The patient was a young guy and routinely checked his own blood sugars and was probably okay. But it still scared the absolute crap outta me, and taught me a valueable lesson about having someone check your meds with you, even as an experianced nurse if you are unsure of something. I still feel guilty about it, and wonder if the pt suffered really bad effects from it, and wish I had caught it before he went home.
We were taught in ns to never draw up more than 10 units. Just curious, how often people draw up more? also, good for you for admitting your mistake and calling the floor. That took guts. Would love to have you by my side at work!
We were taught in ns to never draw up more than 10 units. Just curious, how often people draw up more? also, good for you for admitting your mistake and calling the floor. That took guts. Would love to have you by my side at work!
I once gave 12 units for a bs of over 500, but the doctor was aware and I checked the bs an hour afterward to see how the patient responded to the insulin.
I made an error that I felt awful about two months into my first job... my patient was getting percocet as a standing order. he was going thru etoh withdrawal, had a hx of liver problems among other things. i got there at 7 am, and he had received his percocet at 6 and wasn't due again until 12. he was complaining of severe breakthrough pain around 10, very tremulous and easy to see he was in distress. the doctor ordered 2 percocet tabs for pain right then. after that, when it was time to give his standing dose, i automatically got and gave him two tabs when the order was for one. i did that TWICE. i was so mad at myself for just quickly skimming the order and assuming i knew the correct dose. i told the doc, she was pretty nice about it, but i was hard on myself about it. the patient was happy, though- one percocet did not do enough for him and he said two did the trick- so i guess he needed a reevaluation of his pain management anyway. i just felt (and still feel) bad, given his history of liver disease and overloading him on pain meds. i wrote up an incident report but my manager has not spoken to me about it.
JenNJFLCA
447 Posts
I made a med error very early on: as a student nurse! I was on a postpartum unit and one of my 2 pts needed a vaccination for rubella. I was in the room with Pt A and dicussed the shot with her while the nurse was present. Then I helped Pt B get into the shower (made sure she was steady on her feet since she had a C-section). The nurse came into the room and said, "don't forget to give her the rubella vaccination with your instrcutor." It was at that point I was convinced I had to give Pt B the vaccination. So, I went with my instrcutor, drew it up, looked at the MAR (the MARs were kept all in the same place--something my current unit does not do, Thank God!), discussed the 5 rights with my instructor, walked right into Pt B's room, checked her armband and asked her DOB, and gave her the vaccination. A couple minutes the later, the nurse asked me if I had given the vaccination to Pt A and I felt my heart leap out of my chest. I felt HORRIBLE. Of course we had to fill out an incident report and explain to Pt B that she was now extra-immune to rubella. My instructorwas very understanding, esp b/c she had been with me for the whole process! I kept it together on the floor, but I just cried and cried when I got home. I almost quit nursing school that day. It was a year before I felt mostly OK giving meds. I've had my license for over a month now and I triple, quadruple times check my 5 rights. I am obsessive about it. Sometimes I get that "did I give the right pt the right meds?" panic in my head, but at least it keeps me on my toes and makes me that much more careful. I never allow myself to rush, no matter how behind I am. I ALWAYS look up drugs I am not familiar with, no matter how long it takes. I was fortunate my mistake was what it was, but I truly believe it has made me a better, more vigilant nurse. Rumors in my program spread how someone had done a med error, and everyone was like, "Well, what kind of nurse are they going to be? Not a very good one." Yeah......well, at least I can admit to being human.