Your Worst Mistake

[aurora_borealis]

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.

[Jay2daq]

I once was to administer "Rogaine"...yes Rogaine! I was really confused because i knew Rogaine was used for hair growth. instead of looking it up, i gave the patient her Rogaine, without looking at her blood pressure! (which i was 86/40). Gave her a couple of her other medications. Nothing serious came of it, had to give her a bolus. but i did learn from this to look up ALL medications if its one im not used to giving. I think on our units we get so used to certain medications and when we see a new one we just can sometimes go ahead and give it....

Now that i look back on it, What was i thinking?? Hair growth medication in the hospital?!?!? REALLY JAYDA? ...

F.Y.I. Rogaine is used to lower BP. Its side effects is hair growth (thats where they got rogaine)

We learn from our mistakes and just hope and pray its not a serious one!! Thanks for everyone sharing their stories.

[Nurse4life09]

I shutter thinking about this, but have since learned from my mistake. As a new grad with only a few month's experience, I was working on a neuro/neurosurg floor. I cannot remember what disease my patient had, but something neuro. The R1 was doing something spinal, and asked me to give the patient 2mg Ativan and 25mcg Fent routinely over a period of about 2-4 hours (I cannot remember). So over the course of that time frame, I gave the patient about 8mg Ativan IV and who knows how much fent, 100mcg? 200? I really had no idea. Turns out, I was performing conscious sedation for a patient with an R1 on the floor. But I thought it was ok because I was with a "doctor". The doctor must've thought it was OK because they must perform this with RNs (in the procedure room) Finally towards the end of the shift, I think I finally told someone that I thought it was wrong, but it was too late, though the pt was still alive, the night nurse just had to check vitals every 30 min. The patient was pretty much "hungover" all night and all the next day. I was so embarrassed during report the next morning. One of the nurses said really loud, who in the heck would give a patient that much medication? and everyone laughed. No one knew it was me, except for my charge nurse. I had a chat with her later that day, and I think I got written up, but she also said that I didn't know because the R1 asked me to do so. I still don't know how I could've taken that much meds out of the Pyxxis, but it allowed me to, I guess by having a witness to waste the med?

It's been a while since this has happened, and I have learned to always ask another nurse if you are unsure, to brush up on what can be done on said floor, especially if you need to question the doctor, resident or not.

Also, a patient was allergic to oxycontin, and I gave the patient oxycodone. I dont know what I was thinking, I reported it to the doc, and he just laughed and said, wow, I should've checked that myself. Nothing happened. The patient was cool about it. Turns out, the allergy was "n/v"....hate that!!!

[syckRN]

I had been a nurse for about a year. I had two chest pain patients in the ED and both were so unstable that I was literally standing between their stretchers so I could watch them both. Both of their blood pressures fell due to the Nitroglycerin infusions and I had them BOTH in trendelenberg. One of them kept saying, "Something is wrong." I know that when patient says this...they are usually headed for the drain.

Turns out, another nurse who had come in to "help" me had supposedly started a NS bolus on the patient. Unfortunately, the Nitro gtt was piggybacked into that line...the patient got an entire bottle of Nitro in 15 minutes!!

The half life of Nitro is about 7 seconds. The patient lived.

I however wanted to die!

That was 14 years ago. You can bet your sweet ?*& I never made that mistake again.

SyckRN

[Morainey, BSN, RN]

I know this is an old thread but...

My worst mistake so far has been putting the wrong ID band on a patient with dementia, but who could say her name and birthday.

SUCH a dumb mistake, I even made sure it wasn't too tight that it cut off her circulation but not so loose she could pull it off, and took out my nursey scissors and snipped off the excess so it wouldn't be flopping around in her dinner tray. All without ever LOOKING at the ID band.

Didn't get discovered til evening shift though (I work 7p to 7a) - what's the deal with that :uhoh21:

Now you better believe I check that ID band the first time I walk in the room, and any time I medicate that patient!

Before that, I was beating myself up about infiltrating an IV (not massively, but it sure seemed that way). Just NS, and the swelling went down pretty quickly, but I felt awful about it.

[MomRN0913]

I know this post is a few years old, but I have made a mistake ONCE with diprivan (propofol) aka milk of amnesia.....

This patient was vented and on diprivan. A very small lady. SHe was very active, even while on diprivan. It took A WHOLE LOT to knock her out. Anyway, I was changing the dose, increasing it a little and ended up adding an extra digit to the rate without realizing it. Luckily, I decided to stay in the room and clean up. I remember thinking to myself *wow, she sure is sleeping really good now* Took her b/p and it was in the 70's. I was like *holycrap* I felt myself melting to the floor. I turned off the drip fast like, and almost a minute later she was waking back up and being her own self again. Thank goodness diprivan has a fast half life. After that I always triple check my dosages on the pumps. For a few weeks, even on my breaks, I would call back up to the unit and ask my covering nurse to go in the room and recheck my drips.

Oh bejesus, I did the same thing! I thought I was the only one.... 15 mintues passed and i noticed a hr drop. I shut it off and he woke up loud and clear in like 5 minutes!!! I almost passed out.

My coworker did that with a cardizem drip......

[Nebby Nurse]

Some years ago when I worked in the nursing home industry I cared for an obese tube feed grandma with advanced dementia. The tube was out and I grabbed a new one to replace it. Couldn't insert and thought :This thing has probably been out for hours... So I decided to spare the poor resident the disruption of a trip to the ER. I started poking the opening with a wooden swab. Grandma is looking at me and saying "ah argh ah". After a few minutes of poking I assess the situation and realize I am poking her'inny' belly button with my wooden weapon. One of many idiotic mistakes.

[Trekfan]

This is not nursing one but it was a big one ! I used to Handel some stuff for the mill.and gov. That also meant I dealt with embassies one day I got a call from JFK about some paper that was not right and this shipment was for an embassy ( they have there own planes ) so I had the plane and "crew" held well I handed the paperwork off to the right people but later got busy and FORGOT I had the plane and crew of hold !!!!!

[Jenni811, RN]

as a newer nurse, i can say i have made mistakes...they have been very minor thankgod!!! But i've learned from them.

All i can say is, trust your instinct with giving a medication. When something just doesn't seem right, you can always ask the doctor. i would say 90% of the time i am correct, because phyisicians ARE people too. They can make mistakes just as easily as nurses. I once had a doctor order Potassium IV for a patient who was in fluid overload and was taking oral supplements just fine. I called the doctor to let him know that if i give the potassium IV that would be a 500cc bag, which is the same size bag as our bolus, and the patient is taking oral just fine. Doctor thanked me and discontinued IV order and reordered for oral potassium

Or another Example:

"Mr. Jones is going in for a heart cath this morning. Do you really want me to still give that lovenox?"

Usually they appreciate your call. Even if you are wrong and that is the order they DO want, they rarley ever get upset for questioning that order. Cause if you question it, it is usually for a good reason.

I once still did not feel comfortable giving the medication the doctor ordered (a WAY WAY high dose of opiates who was already given a very high dose and pretty much knocked out, respirations ok but still...). After doctor still said "yes that is what i want" i actually consulted with the pharmacist on our floor and had him talk with the doctor. The pharmacist agreed with me on this one. The doctor was upset with me, but honestly....i know where the patient is at this point. The doctor didn't see the patient before ordering the med.

[FlyingScot, RN]

Guys, as helpful and interesting as this thread is I think you might want to think a bit before admitting these kind of mistakes for EVERYONE in the world to see. These forums give the illusion of anonymity and there is still the possibility that someone could figure out who you are.

[whichone'spink, BSN, RN]

I gave Plavix to a patient who was thinking about having a lap chole but it wasn't a done deal yet. Shortly after I gave her medications, the doctor came in and she said she wanted to go ahead with the lap chole. She needed FFP and platelets. The primary nurse told me the next day, and somehow my instructor did not find out. I will not do that again, that is for sure. Better to make mistakes as a student than as a licensed practitioner.

[Nurse3000]

my goodness glad you came out the other side.. im sure you havent made a mistake like that again!

[Nurse3000]

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

absolutely horrible. wouldnt wish on worst enemy fate of those poor nurses and the poor pt. shocking