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, LTC.

My biggest mistake was.....

in a LTC facility that I worked at several years ago, the midnight nurses did the morning fingersticks and the day nurses gave the insulin based on the FS that the MN nurse got. So that particular morning the day nurses were "staff challenged" and we decided to give the insulins for them, since breakfast was not that long away. So I gave the required insulin for one resident and charted it in the MAR and then specifically stated in my taped verbal report that the insulin HAD been given. Several times I emphasized it. Well the day shift didn't bother to listen to report and gave the insulin again...my mistake was when I signed the MAR, I signed the wrong time. I gave the right dose for the morning dose, but signed the evening dose...so when the day nurse went to the MAR she gave the AM dose. then she listened to report and realized it had already been given and that she gave the second dose. I never got wrote up, and the resident was ok, and her family was really cool they said "your only human, things happen, shes ok". You better believe I double check double check double check!

3 mos as a nurse and I have a 60 y/o pt. who is in for kidney stones, but has a long Hx--l sided palegia from CVA, diabetic, dementia (and he was actively hallucinating while I had him); also, he wore a CPAP at night. This was my second night with him, and it was after his stone removal procedure. First, some time after midnight, his wife called saying he was having trouble breathing, so I called RT and he told me the CPAP was not on correctly.(0440) he was in pain, so I gave him a couple vicodin. About 40 min later he was trying to get out of bed to answer whoever was knocking on his closet door, so I gave ativan 2mg IV. At about 0600 I started to do my final rounds to reset IVs and make final checks. To this day all I can say is that all appeared to be ok. At 0730 I should have been home, but I stayed for an inservice for the hemovac when I hear those horrible words over the speaker--code blue, room 420...I jet outta the room to see them performing the full code. I saw they didn't have anything to take a temp, so I ran and got a tymp thermometer--91.4. He wasn't coming back. Next I went to the bathroom and sobbed. Before I went home, I spoke with the NM, day charge, the minister, and the wife (who was there the entire time). I couldn't get the thought out of my mind that maybe at 0600 he wasn't really breathing; maybe if I would have stayed just a moment longer and been certain, we could have saved him if he hadn't been breathing. Also, I kept thinking, maybe the combo of drugs I administered gave him the extra push over the edge. And to add, the wife was questioning whether anyone ever checked when she called about her husband having trouble breathing. And if things weren't bad enough, I hadn't charted when RT checked him, and had forgotten the time he readjusted the CPAP, so when I charted after the fact, I most certainly put the incorrect time. Despite what everyone was saying, I knew my license was a thing of the past. And worst yet, I didn't even have any legit defense, because my charting didn't support my efforts if any kind of lawsuit/charges were to come up.

***Lessons Learned--When I enter a room, no longer do I think all is ok; I don't leave until certain. Also, chart when it happens, or immediately get it onto paper for future reference. I believe I didn't cause his death by my actions, but to this day I can't help but have the least doubt about whether he was breathing or not. But by the grace of God, I will not allow such a situation to occur again.

We have ALL made mistakes. Get plenty of rest before work and don't work at anyone elses pace. You know what you can do and what your safe speed is. I also agree it's better to fess up when you make that error. I've (and you have too) known nurses that don't fess up and hope for the best. Not a good idea.

-R

Specializes in Gerontological Nursing, Acute Rehab.

I'm shivering remembering these horrors. I've learned that no matter how busy and frazzled I am, never ever ever ever let your guard down.

I shiver, too, when I think of my big mistake.....

I used to work on a very busy sub-acute/rehab/vent unit. I had 16 pts....3 on vents, 2 trachs and about 3 GT's. There was a very brittle diabetic on my assignment. Now, day shift always gave out the AM insulins, but very rarely if night shift was quiet, they would give them out right before report, since day shift started out so hectic. They would ALWAYS tell us when they gave out the insulins. (you see where I'm headed, right??)

Of course, it was a hellish morning....the vent patients needed adjustments, my trach pts needed suctioning.....the breakfast trays were coming and I didn't even get near my med cart yet. I decided to quickly give this woman her insulin before she got breakfast, since it was imperative in her case that she got her insulin before she ate. Well, I gave it, and went to sign it out......and night shift had already given it. They didn't tell us that during report.

Quickly I told my other nurse that night shift already gave out the insulins so she didn't make the same mistake, told my super and called the doc. Of course, the pt. bottomed out and needed IV Glucogon, but we managed the situation without any long term effects to the patient. I was such a wreck that day.

A mistake that was EXTREMELY preventable.......you are told over and over again in school to check and double check....but when you are in the "real world" of nursing, it's easy to get so busy and frazzled that you just don't do all the things you're taught. But, I learned, and I can tell you that I have never, and never will, make a mistake like that again. Too scary when I think of what could have happened. :eek:

nurse1975 25

You poor thing, it sounds like you have had a very bad time of it.

I was wondering how long ago your "experience" happened? And what are you doing with your time if you are not working as RN?

Ms HB

Hugs to all nurses. Sometimes the hardest thing is forgiving ourselves...but we are all very human and perfection is not an option. Something many facilities and managers seem to dispute.

my biggest mistake was...going to nursing school :rotfl: just kidding

1 Votes

I'm having anxiety attacks just reading these.

My biggest thing is we are so poorly staffed when you consider what can easily go wrong with one patient. Or even God forbid more than one. I gotta stop this I am in such a panic now.

The unit I work on is a oncology unit, although we also get medical pts as well. We had a new RN that had been pulled from another floor on night shift, and she was assigned a pt who had been on our floor 2 days. This pt was in for etoh abuse, and had been going through DT's, and was recieving ativan iv. He had not slept for days. The nurse also had a ca pt who was receiving dilaudid for pain control. She had drawn up in two syringes the ativan and dilaudid to save time, and gave the dilaudid to the etoh pt by mistake. The pt went out, but was breathing. All night the pt slept, and the nurse didn't take vitals or disturb the pt because the charge nurse on nights told her to not disturb him since he had not slept in days. The new rn had tried to wake him, but he would not wake up. When The narcotic count was being done, it was discovered that the nurse had given the wrong med to the wrong pt. Still no one checked on this pt. When we got out of report for day shift, I went in to assess this pt and I could not wake him up, not knowing what had happened on night shift because it was not passed on in report and the night nurses had already left, The pt sat was in the 50's, and had probably been there for a long time. The New rn, and the assistant nurse manager both lost their license. The pt is a vegtable still in our hospital, not on our floor of course.:crying2:

Specializes in Rehab, Step-down,Tele,Hospice.

OMG Whata nightmare!

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.
The New rn, and the assistant nurse manager both lost their license. The pt is a vegtable still in our hospital, not on our floor of course.:crying2:

Yikes. What a nightmare indeed. Question, why did the assistant nurse manager loose his/her license?

Specializes in Med-surg; OB/Well baby; pulmonology; RTS.

I know I've made mistakes. I can't recall my worst one at the moment.

I really do not like the days I go home wondering if I did this or that...those are the days that scare me. :stone :o

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