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've spent the last few days reading through this entire thread. I'm a new RN *grad in May* and am finding the entire thing informative, relieving and petrifying all at the same time. So far I'm fortunate not to have made any truly crucial errors. Orienting as an OR nurse, most of our meds are given by anesthesia docs. There are many things we do that can result in harm to the patient but having 1 patient at a time plus a preceptor by my side (most of the time) there is a lot less likelihood of error. However, it can and does happen.
Errors outside of med admin are the ones that trip us up. I made the mistake of accepting demonstration of the proper way to open and pass off alloderm tissue onto the back table rather than reading the directions. I had been taught to open the outer package and allowe the scrub to extract the inner package. So, that's what I did the next time I had a case that needed it. So did my preceptor. Then I happened to read on the front of the package - yes, right there on the FRONT, didn't have to open an instruction booklet even - it states that the inner package is NOT sterile and that it has to be opened by nonsterile personnel to be passed. I see this and point it out to my scrub, preceptor was out of the room at the time, and her eyes turned into dinner plates. I left and got my preceptor to tell her what we were doing wrong but mostly so we could tell the surgeon together as he is one of our more pita docs. Preceptor was horrified as she's always opened it that way. Our dept educator was in the hall and we talked with her about it and she was bug-eyed as well...and thankful she wasn't the one to have to tell this doc the news that the grafts he was stitching into the patient were contaminated. We cringed and cringed and cringed, finally worked up the courage to step back into the room. Then we cringed some more before my preceptor finally speaking up to the doc to tell him that we had opened the pkgs incorrectly and the product was contaminated. To our surprise, he didn't scream like he usually does. He made some comment about it couldn't be helped now and we'd just make sure to give extra antibiotic. Since my preceptor told the doc, I said I'd call and talk to our director to tell her what happened so she'd know what was going on before she got her copy of the incident report via email. She was awesome, never said a negative word. Thanked me for letting her know and for taking care of things. I never heard another word about it from anyone. I never told anyone that the person who taught me how to open it was the same scrub who was in this case. Our educator and my preceptor asked and I told them I couldn't remember it had been so long but since my preceptor was also opening them incorrectly nobody pushed it seeing as how it was clearly a problem before my time. Needless to say, by the time the case was over everyone in our tiny OR unit had heard about it. Nobody was nasty about it though so I was thankful. As far as I know the patient was fine so lesson learned. I think there was a unit wide email with info on how to properly open those packages and maintain the sterility of the contents onto the sterile field.
Later the same day after that incident, we were positioning an anesthetised patient into prone position. Once prone, the LPN on the side opposite me was rotating the person's arm to position onto the arm board and the end of the picc line was ripped off. I don't know if it was done when she moved the arm, when the chest rolls were placed or when we flipped the patient prone. Since I was on the opposite side I couldn't see but given the circumstances and what was going on, I have a feeling it was when the arm was rotated. It was still my patient, my room, my responsibility and I should've been watching out more closely. Being the orientee working the room without a preceptor, I was trusting that the LPN helping to position was being cautious about such things on her side of the patient. Once again, I had to tell a surgeon something about his patient that shouldn't have happened. This guy is usually nice but has his temper tantrums. I got the patient situated, cleaned up, gave report to the relief nurse and went to find my surgeon. I told him what had happened and he was very cool about it. Someone had already told him and he said it was no big deal (I beg to differ) and they'd just put it back. All well and good, thankfully the patient was already having surgery and it wouldn't incur quite the cost as a seperate procedure but still....
Those are my two biggest mistakes thus far. I would love to live in denial and say I'll not make another but pppppfffffftttt we all know that ain't gonna be the case!!! I can't thank everyone enough for sharing their humanness. It scares me to death to know that *someday* will come and I fear what will happen to my patient for my mistake. I dread it.
On a positive note...recently I had a preference card that called for the mixing of two drugs into NS onto the back table. One of our scrubs saw me looking up the meds and asked what I was doing. I told her and she looked at me as if I were insane to even think of checking them. She told me that while it was good that I was being cautious and all, with *that* doc I could/should just accept his orders because *he knows his stuff*...some other docs it would be good to check though. I told her that while he probably does know his stuff, I don't know it all and I wanted to be in the habit of checking rather than assuming and if I skip checking this one it'll be easier to skip another one and regardless of who ordered it, I have to be responsible for knowing the drugs I'm administering and if I miss checking one and a patient is harmed, it's my license. She accepted it as a good thing...that I was using it as a learning tool, not that I was being responsible for the meds I'm administering. Oh well. LOL It clearly isn't her license.
Thanks again, EVERYONE!
You sound like a good consciencious nurse. Good luck in your career. You took the most important steps after a mistake, accept responsibility and learn from it.
I gave 15 times the amount of a medication. The patient did not die, but it was a terrifying experience. To make matters worst the hospital is turning this medication error to the state licensing authority. I thought about quitting nursing, but I worked too hard for my license. Any suggestions on what could hapen to my license?
What type of medication was it and what was the effect on the patient?
Hospitals don't have to report to the BON. I don't know why and when they do. Many med errors are made in any hospital, I have never known anyone to be reported to the BON in any hospital I have worked in.
If I were you, I would consult a lawyer and have him/her represent me in any dealings, correspondence/hearing, with the BON.
DutchgirlRN;1896474 wrote "I had an order once for 100mg Morphine/Phenergan 25 mg IM Q 4 PRN Pain. The student I was precepting didn't question it because it was a doctors order and must be given as ordered. I called the doctor..."Um dear doctor _________, I'm assuming you meant 100mg of Demerol IM Q 4 and not Morphine? Would you like me to correct that order?". God yes and THANK YOU so much for saving my a**."
Just out of curiosity since I am still a prenursing student, how did you know looking at the order for 100mg Morphine/Phenergan 25 mg IM Q 4 PRN Pain that it was wrong and should have been 100 mg of Demerol IM Q 4? How did you know it should be Demerol? From the 100 mg? Why not ask if he had the mg of morphine wrong? Thanks.
Specializes in Critical Care, Cardiothoracics, VADs.
Yes from the dose. As an RN you should know the normal prescribing range of meds you are giving, and question orders that are way out of that range. You'd expect to give 10mg of morphine, not 100!
Under the direction of a physician I transfused a patient 2 units of blood.
After the transfusion he c/o not feeling well, SOB. He was in CHF. I freaked....called the doc who came and assessed him and then said....maybe we should have waited until he went to dialysis tomorrow to transfuse him! So, off he went to the dialysis unit and came back healthy, happy and with a lovely hemaglobin.
Felt like an idiot. The doc shrugged it off. My co-workers were clueless. Will never forget that!
Yes from the dose. As an RN you should know the normal prescribing range of meds you are giving, and question orders that are way out of that range. You'd expect to give 10mg of morphine, not 100!
Maybe I shouldn't respond to your comment and maybe your comment isn't directed toward my post about knowing the amount of morphine to give, but I know nothing about most meds and how much is the right amount. As I noted originally, I am still a pre-nursing student and have not had any classes in nursing much less medications. I agree as an RN you should know the normal range of how much of a med to give.
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medsurgnurse, RN
401 Posts
You sound like a good consciencious nurse. Good luck in your career. You took the most important steps after a mistake, accept responsibility and learn from it.