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 Aged, Palliative Care, Oncology.

thats nice of you nurseie 30 to keep on supporting, more nurses like you pls.

Boy, admitting is hard, but we know we have to do that, forgiving ourselves is almost impossible.

I was fresh out of LPN school, working evening shift by myself, pt chokes in dining room, I called out for a code status, the SSD went and checked the chart, running back in and yelling, "She's a Full Code" so I began CPR, the pt was revived, the EMT's arrived, and about 30 minutes later the hospital calls, and notifies us that the pt was a DNR on their records. I went to check her chart, and although there was no yellow flag in front of chart, or a sticker, or even an order on the current MAR, looking back about a year, there it was, the Doctor had wrote an order for her to be DNR d/t terminal illness, it was never pulled forward. She was in the hospital for about a wk, and I was so worried about the state that she would be in when she came back, but she came back as the same old fiesty lady, which made me feel better. But just imagine, the adrenaline of the code, excited about actually doing a code successfully, people patting me on the back, feeling 10 ft tall, and then the call saying that she was a DNR.

So....my big ole soap box wherever I work is asking what the status is, asking what the family wants if they've changed their mind with decline in conditions, and making the SSD aware, nurses, CNA's, whoever what a pt's code status is.....it was a horrifying experience....

On the lighter side, I have inserted a foley in the wrong "umm" area, and reported no output at end of shift, to have dayshift find out, I wasn't a very good mark.

And we all know how scary it is when you realize that you have given the wrong meds to the wrong pt, fearing the worse, not wanting to call the doctor, and kicking yourself the whole time knowing that is was just plain dumb, or rushing or whatever.......

To the RN that quit because of the Insulin? You really need to get over this, 50 Units was a tad bit too high, but we all make mistakes, don't give up something you love......that is so sad......you are probably a very competant nurse, obviously caring if it has affected you this much, go back to doing what you love.....

Specializes in ED.

Getting married

Specializes in Emergency, Trauma, Critical Care.

Worked in critical care and this genius doc decides to stop the levophed on a pt "to see what would happen. " instead of just pausing it. He took it off the pump and threw it in the trash. I have no idea what made him think that was a good idea...

I run to mix another get because his pressure was tanking fast. The pt was almost maxed out on levo...I was so mad because if he didn't need it he would have been titrated off!

I get in the physics and pull two vials of levo because the concentration was 8 mg and grab my 250 bag. I grab a nurse for my double check. She gives the nod. I look at the vials one last time and realize it's a neuromuscular blockade. ...it had been loaded in the pyxis under the wrong section.

I break out in cold sweat. I go and grab the right vials from another pyxis and mix the med for the pt. Get his BP out of the 60s....

Call pharmacy. ..send they're there the fastest I've ever seen them fixing the meds to the correct pyxis.

I was so grateful I slowed down and finally look at what I'm doing. He was not tubed and probably would have coded because of me not reading the vial and just assuming the right med was known the pyxis.

Another time I took over an assignment and this pts BP was in the 70s a day had been all night from the trends. The night nurse was still charting and I checked my levo all the way up. ....it was azithro that was hanging. I informed her and she tried to bully me into not reporting. But the error would have fell on me had I not.

I felt bad because her and another nurse got written up for it among other things. It had been hanging for over 24 hours per the MAR.

That's when I realized the facility I worked for wasn't interested in being safe, they were interested in writing up staff and assuming human error wasn't expected. I still have PTSD from that hospital.

I know this is old but that's a good one, I was scared for you just reading it!

I didn't read all the pages of comments, so I'm sure someone else already asked about this - but, doesn't blood have to be in within 4 hours? I wish I worked with understanding people - they were only understanding while I was working with a "popular" preceptor - after that - every mistake I made or anytime I asked for help I was made to feel stupid - in fact one experienced nurse who is assigned to walk the floor and help other nurses actually calls nurses stupid idiots all the time - usually waits until she's with other nurses and that nurse isn't around -but if she doesn't to one nurse in front of me - I'm gonna assume she's doing it to me in front of them....

Specializes in Psych (25 years), Medical (15 years).
Getting married

Twice.

Third time's a charm.

Specializes in NICU, ER, OR.
Not only are nurses human, so are doctors. I have a personal experience regarding a doctor that made me realize that they too are only human, and they have even bigger consequences to face. My oldest son who is now 5 was diagnosed with a life threatening heart condition by accident. I took him into the ped. because he had a bad cold. Our ped. was out on a leave so we saw a different doc. He did a full assessment on my son since he had never seen him before, thank goodness. Anyway, he heard a murmur, which had never been heard before, and got a horrible look on his face, and said that we need to go to a ped. cardiologist within the next week. We had an appointment set up, but I had to take him back to the ped. a couple of days later because his URI was getting worse, by now his regular ped. was back. She listened to his heart and said it was a normal murmur, and to not even go to the cardiologist. Well, I did because of the look on the other doc's face. Two months later we were at Stanford Medical Center having open heart surgery. We live in Seattle, and were told they couldn't perform the surgery because they had only seen my son's condition in autopsies. Our regular pediatrician made a mistake, we still go to her becasue we really like her,and she is human. Many people we know think we're crazy but I have to say, when we go in, or call, we get fast treatment, and all of my kids get a more than thorough check each time. I think everyone needs to realize that we all make mistakes, but as long as we learn from them that's what counts. If there's anyone reading this from Lucille Packard Children's Hospital, or Stanford, thank you, even if you did not have anything to do with my son's care, they are both wonderful hospital's. And Dr. Hanley is a miracle worker!

Seriously? That doc totally and completely missed a heart condition, ignoring the murmur.. your child needed open heart surgery-- yet you STILL trust this doc with your children's healthcare??? WOW you are far far more forgiving than I.. I would have , among other emotional things, sued his ass off...

Specializes in Medical/Surgical/Telemetry RN.
my biggest mistake was...going to nursing school :rotfl: just kidding

HAHAHA!!!! OMG! Thank for the laugh!!!

Specializes in ER.
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:

THESE MISTAKES ARE NOT THOSE OF A FABULOUS NURSE.

I'm pretty forgiving, and I've made some doozies, but for maybe the second time in my allnurses life I'm saying that if one nurse made all these mistakes, s/he needs to stop before someone dies.

My worst mistake... piggy backing magnesium and delivering an excess of 100mg to a patient. I was told by the pharmacy to just hang the bag and set a timer, which I did. But I should've known that the timer wouldn't stop the infusion since it was piggybacked to a bag of saline that was set to run by the hour. The whole bag of magnesium was given to the patient. She did not suffer from any physical side effects, but her Mg labs were critical high by a couple of points. Got MAJORLY chewed out by the on call doc. But her actual doc told me to just "not do it again." He was super chill about it, and the patient was released two days later. I was investigated, but ultimately they found pharmacy to have violated a policy on providing exact doses of electrolytes for infusion. It actually traumatized me, but about two years later, I'm finally finding peace.

Specializes in LTC, assisted living, med-surg, psych.

I didn't make very many med errors during my career, but my worst one was the time I gave a Lovenox injection to a patient and then gave him a heparin shot on top of it. He and another man with the same first name and similar last name ("Harry Smith" and "Harry Smythe") were in rooms next to each other, and I simply did not do the five rights. Stupid thing is, I was questioning in my mind why the poor guy needed heparin AND Lovenox, but I misread the name on the MAR and ass-u-med he was getting both. Long story short, I discovered the mistake when I went to give the other patient his meds and saw the heparin order, then quietly freaked out before I notified the doctor of what I'd done. I couldn't believe it. I felt like the worst nurse in the history of the profession. This error came at the tail end of my career, and it made me realize that the difficulties with attention and focus I'd developed over the previous couple of years made me unsafe, and I needed to quit before I killed somebody. Luckily no harm came to the patient, but I still shiver whenever I think of the incident.

Thank you for sharing your story, I come here today because I'm having a situation myself. I work in a nursing home as a new grad,same shift as your noc shift. Today one of my PT had a COC and I called the ambulance and it took so long due to a lot of traffic. I tried to control his pain, but it was severe, his BP when up, and the situation escalated too fast, the ambulance took so long and I suspect he's having a CVA. Finally the ambulance came, and took him to ER. I feel so terrible, I keep crying for him, because I know how bad that can turn to be. While we waiting for the ambulance he was telling me why are you doing this to me? when I'm doing all I can possibly can do. My Manager came and he told me that everything is going to be ok, but I feel so screwed. I feel too bad for the PT that experience that pain. Now I'm scared that the family might get mad with me and sue me for the whole situation.

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