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 am also a student nurse and will be graduating in less than a month as an LVN, of which our main job is to give meds. I am thankful to you all for being brave enough to tell us your mistakes so that we may learn from them. I have yet to make a big mistake (once missed a vitamin supplement in the nursing home---but, it's still a mistake, though not life threatening) because of the constant supervision and checks that are integral with school. I am frightened that I will make a mistake when I graduate when I don't have an instructor holding my hand. I will be moving to a considerably larger town than where I have done my clinicals and will be working for a hospital that does massive amounts of student teaching with the university in town (Texas Tech). I'm nervous that this larger atmostphere will cause me to have to "hurry" myself to keep up with the workload, but as someone said previously, never let your guard down. It really is mindboggling how we really can hold the pt life in our hands. Cheers to you all who stood your ground, those of you who admitted and learned from your mistakes and all of you who were willing to let us in on your horror and fright so that we may learn from them. This thread has really been an eye-opener for me! Thanks :)
Is it always the nurse's fault when an IV infiltrates? I am a student, and just two weeks ago I was giving an antibiotic IV to a guy, my instructor was right there with me. I flushed it with saline first, which went in fine, so I started the IV and went to get the linen to change his bed with. I came back, and it had infiltrated. I shut the pump off immediately and called the IV team. About 15 cc had gone in. I didn't think this was my fault, but now after reading your posts, I am not sure.
No, it's only the nurse's fault if s/he doesn't notice it, like I didn't, after a unit of blood infused. There are many reasons for an IV to infiltrate, usually has more to do with the pt's veins, the position of the catheter, and if the patient is combative or picking at it. You did the right thing by stopping the infusion, but you should also remove the IV and put cold packs on it to reduce swelling. And remember, when you pull an IV for a restart, ALWAYS remove the angiocath, better yet the extenstion set if your hospital uses them, and cap the tubing with a sterile plug. When I worked on the IV team, nothing irritated me more than being called for a restart and seeing the whole system flapping in the breeze, totally contaminated.
Oh, my gosh, where to begin? I'm very lucky that I almost made a terrible med error my first year of nursing - I drew up epi instead of inderal to give iv push to a patient in svt (this was way back in 1974)...would have killed the person if I hadn't realized what I had done before I gave it. This taught me very clearly that even I can make a mistake (I'm kidding here guys) and I am very careful when giving meds.
One thing has helped me. I have a few rules that I never deviate from:
1. I never give medication that someone else has drawn up (even if I see them draw it up - they can give it). Same thing goes for po meds unless they're still in their little labeled pack.
2. I never have more than one syringe in my hand unless they are both labeled. Yeah, I think I can remember that the phenergan is in this one and the saline is in that one, but then the phone rings or another patient vomits and I lose my train of thought...
3. When I get that funny gut feeling, I double check and then double check again. There are some things which should sound the alarm (like that patient saying "that looks like a lot of medicine in that syringe") or when it takes 20 vials of something to get the proper amount of medicine.
4. I always ask allergies before I give the patient the medicine cup or give an injection. I can't tell y'all how many times a patient tells me they have no allergies when I triage them then right before I give them the shot, they say, "no, no allergies other than penicillin".
5. This is a gut feeling one too. If the doc says to give something I'm unsure or uncomfortable about, I double check, make sure it's in writing and double check again. I won't give anything that I know is wrong - like inderal 80mg iv - the resident swore up and down it would be okay. Then wouldn't give it himself when I refused to give it.
6. I save med containers. I look at the label before I break it open, as I draw it up, after I draw it up and then after I give it. Compulsive I know, but better to know you screwed up as soon as possible.
These rules have helped me avoid many med errors, but not all. I have noticed that most medicine errors are communication errors though. I thought the doc said talwin, he swears he said tylenol #3. It helps if you can have everything in writing first. Since I work in the ER it's not always possible.
My worst error wasn't a medication error. I took care of a 17 yo boy who died in the ER during a terrible asthma attack. The doctor was in a room with all of the family telling him what had happened. Two family members came down the hall from that direction asking me if they could see "Paul". I said of course, and went with them to the room. As I took them in, one of them said, "Oh, my god, is he..." and I interrupted and hussled them out of the room and back to where the rest of the family had gathered. I really thought they knew about the death and wanted to see his body. I felt awful, but these people were actually very understanding.
I accidently gave a large skin tear on the forearm to one of the res. at the nursing home I used to work at as an STNA. I was trying to feed her lunch in her room, most res. went to the dining room to eat but she was disruptive and yelled out SOS all the time. The other res. would get distracted and not eat if she were in there. Anyways she usually tried to push your hands out of the way and I tried to gently restrain them in her lap. She out muscled me and moved her arm across my watch, I think on the part that sticks out to change the time, and boom huge skin tear. Felt terrible, wanted to cry.
My worst mistake as a nurse wasn't a patient error. It was signing a travel contract, having the assignment not work out, then getting losses charged off against my pay by the travel nursing agency and not getting paid a cent. My word to all nurses thinking of travel nursing - read your contract and don't sign anything that says you are responsible for living expenses that these agencies say are free.
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.
16 patients is extremely unsafe. I would never agree to take that many patients. 5-6 is a good amount for med-surg, 3-4 for telemetry/PCU.
The other morning I was busy and feeling really behind. I was trying to rush to get my work done and leave on time. I had a patient that had a dubhoff feeding tube and needed to get all his meds through the tube. The first three meds when down fine and the tube flushed fine. The last med(Bactrim) did not go down easily even when I diluted, but I should have diluted it even more. When I went to do the final flush, it would not flush. I did not want to force the water down, and I didn't want the patient to know that I was having problems.
Anyway, I left it that way, and that was a mistake. I should have fessed up, but I didn't. Made me feel bad all the way home and if I had fessed up, it would have been better. Anyway, the doctor ordered his meds PO, and the tube got unplugged, so all was well in the end.
I guess sometimes as nurses we hope that all will turn out for the best, but sometimes that does not happen.
I've pulled a few. One, working as Charge RN when I was a Staff RN, received a phone call from a female asking about the status of another female (who was active duty Army), this other female was in an AIDS coma. I told the caller her status. Turned out the caller was the partner. MISTAKE? I'd think so.
2, as a student, I informed a patient he didn't have oatcell cancer. I seen the 2nd path report. The 3rd report showed he did. The next day, did I ever hear about it.
3, I'm a former medic. A diabetic with a problem, I opened the crashcart and did an amp of D50. Was that so wrong?
This is actually not my error, but I prevented an ER nurse from giving my 11 year old an incorrect dosage. The doc had ordered Benedryl 25mg IM to head off a mild allergic reaction. My son weighs 120 pounds and is 5'2" tall.(Took almost 45 minutes to get the med delivered, but that's another story). Anyway, the nurse comes in with a syringe and pulls it out of his pocket. I ask him what the dosage is and he says 25mg of Benadryl. I say, ya know, there seems like an awful lot of med in that syringe....to which he immediately does a double take, and says Oh!....and walks over to the sink to waste some!
Man, I hate that ER.........(by the way, I don't work there!)
As a student-to-be, my worst fear is making a ...medication error. I haven't even started school and I've been reading chapters in nursing books about drug calculations, and I practice these calculations when I can. I can see myself as a nurse triple, quadruple checking to see if I've got the right ...medication, delivery route, right dose, and most of all, right patient!
hello student to be.im holly an lvn. in response to your biggest fear i say this.yes do all your 5 checks but also know this that u will make a med error at some point.it is inevitable the thing is that u have to be honest after the fact and make sure dr is made aware so that u can fix it if something does go wrong from ur mistake.everyone will respect u a whole lot more if ur honest and fess up that just means u really care about the patients safety. good luck to u!!!!!!:balloons:
my biggest mistake was second guessing my first thought and taking to long to make the right decision. at the time i was a ...medication aide in a nursing home and that night i was in the med room auditing the carts for reorders. when i came out i saw ems and i had heard nothing inthe med room. soo i went to go see what was going on and found that a res had coded.emts were doing cpr to res and the nurse in charge was standing at the door to room. i approached her to find out what had happened and she said that the aide just found her that way. i asked her if she had initiated cpr and she told me hell no i aint puttin my mouth on that thing. and a few minutes later i had asked the cna what happened and she told me what she found and that when she called the nurse she called 911 and that she just stood there lookin at pt and when the cop that was first to arrive on scene he did the same thing .the res never recieved cpr until ems arrived .had i heard anything i wouldve done it myself but what the problem is that i didnt report it right away to administrative staff as i figured what good would it do it was my word against hers. and at the time i was in nursing school so the next day when i went to class i wanted to get my teachers opinion about the situation so i mentioned the scenario to the class leaving names out.and the next day i got called into the office at work as they said that i broke pt confidentiality by saying what happened and mentioning names which i didnt what happened was that one of my classmates worked at the hospital that the patient was taken to and this was small town so was easy to find out specifics and she called my job saying i broke pt confidentiality.so when i went inthere i explained exactly what happened the night of the code and why i was talking bout the incident and that i hadnt mentioned any names.of course they didnt believe me so i called my teacher and she verified that i never stated a name.anyways the place let me go saying that i endangered the pts life by not telling administrative staff right away(i was getting ready to quit anyways so that didnt bother me)but what bothered me the most was that even after all that i had told them that happened and they had statements from cnas and police and emts the nurse was still working there. some of the cnas tried to cover up for her but all the other peoples statements coincided with mine. sooo my point is to the whole horrible ordeal is report anything and everything even the minute stuff cause in the end it will come back and bite u in the butt.by the way the pt did die and she was a full code. ps sorry bout the spelling and such just tend to get lazy when ur on the comp.
ps sorry bout the spelling and such just tend to get lazy when ur on the comp.
SarahCeleste
32 Posts
I am also a student nurse and will be graduating in less than a month as an LVN, of which our main job is to give meds. I am thankful to you all for being brave enough to tell us your mistakes so that we may learn from them. I have yet to make a big mistake (once missed a vitamin supplement in the nursing home---but, it's still a mistake, though not life threatening) because of the constant supervision and checks that are integral with school. I am frightened that I will make a mistake when I graduate when I don't have an instructor holding my hand. I will be moving to a considerably larger town than where I have done my clinicals and will be working for a hospital that does massive amounts of student teaching with the university in town (Texas Tech). I'm nervous that this larger atmostphere will cause me to have to "hurry" myself to keep up with the workload, but as someone said previously, never let your guard down. It really is mindboggling how we really can hold the pt life in our hands. Cheers to you all who stood your ground, those of you who admitted and learned from your mistakes and all of you who were willing to let us in on your horror and fright so that we may learn from them. This thread has really been an eye-opener for me! Thanks :)