Your Worst Mistake

cantoo · Apr 20, 2004

1984. Fresh out of school. First day on the job. Report for duty and I am handed a tube of lady partsl cream and told it is for pt. So and So in room number such and such. I go in to the room and approach the pt. I explain why I'm there. She protests, saying she has no lady partsl problems. I just assume this pt. is comfused since she's 150 years old, and give the med. Yep. Wrong pt. The poor little gal was allergic to the cream and her poor little lady parts swelled up like a colliflower. :imbar Couldn't sit down for a week. I felt horrible. Of coorifice, the nurse that handed me the med denied giving me the wrong name and room number, but it didn't matter anyhow. It was ultimately my mistake for not double checking. Never again. Every once in a while I still run into a nurse that worked on that floor all those years ago, and she never fails to remind me of that incident. We laugh about it now, but it sure taught me a valuable lesson.

CyndiW35055 · Apr 21, 2004

I am fixing to graduate LPN and yesterday I was doing a clinical on the med/surg floor. My patient, a 42 yof had an iv in her left hand. Of course, most pt.'s that I have seen myself are afraid to use the hand with the iv and have it propped on the pillow. This one did also. Her fingers were swollen a little but not at the iv site or below below the site. There was good blood return and everything was fine. My clinical instructor went to check it for me to verify because the pt. kept saying she was worried because of the slight edema in her fingers. She explained to the pt., just as I had, that the swelling was because of lack of use and keeping it propped up.

About 10 minutes later, the RN in charge went to give the pt. her meds, demerol and phenergan iv, pt. told her she was worried about it. After RN gave her the meds, she proceeded to tell the pt. that the iv was out and that I was "just a student and didn't know what I was talking about" and changed the iv to the right hand. I didn't have the RN tell me what happened, I had the pt. who very quickly informed me that since I didn't know what I was doing, she didn't want a student if they couldn't tell what was going on.

My clinical instructor and myself went to the RN to ask about what happened, and I apologized for not "recognizing" and infiltration just to be told that I was right in the first place, the iv was fine, there was good blood return, and she was just pacifying the pt. She also said it was easier to tell the pt. that I just didn't know enough yet and that I couldn't tell what was going on. So, how do you cope with that type of thing? :uhoh3: HELP!!!!!!!!!!!!!!!!!!

gwenith, BSN, RN · Apr 21, 2004

I still think one of the classic mistakes of all time was the poor yound student nurse who decided to clean everyone's teeth so, in the interests of efficiency she collected all the false teeth and stuck them in the steam sterilizer - now comes to redistribution................... Took a dentist 6 months to sort the mess out.

LT Dave · Apr 21, 2004

Though its not a good thing to happen... infultration of blood is a lot less harmless then so many other thing we push via IV. Relax if the MD had some brains they would have sedated the pt so her would not have to suffer with DTs! Lucky he did not have a sezure from the DTs! :angryfire

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.

nursemjb · Apr 21, 2004

I am fixing to graduate LPN and yesterday I was doing a clinical on the med/surg floor. My patient, a 42 yof had an iv in her left hand. Of course, most pt.'s that I have seen myself are afraid to use the hand with the iv and have it propped on the pillow. This one did also. Her fingers were swollen a little but not at the iv site or below below the site. There was good blood return and everything was fine. My clinical instructor went to check it for me to verify because the pt. kept saying she was worried because of the slight edema in her fingers. She explained to the pt., just as I had, that the swelling was because of lack of use and keeping it propped up.
About 10 minutes later, the RN in charge went to give the pt. her meds, demerol and phenergan iv, pt. told her she was worried about it. After RN gave her the meds, she proceeded to tell the pt. that the iv was out and that I was "just a student and didn't know what I was talking about" and changed the iv to the right hand. I didn't have the RN tell me what happened, I had the pt. who very quickly informed me that since I didn't know what I was doing, she didn't want a student if they couldn't tell what was going on.
My clinical instructor and myself went to the RN to ask about what happened, and I apologized for not "recognizing" and infiltration just to be told that I was right in the first place, the iv was fine, there was good blood return, and she was just pacifying the pt. She also said it was easier to tell the pt. that I just didn't know enough yet and that I couldn't tell what was going on. So, how do you cope with that type of thing? HELP!!!!!!!!!!!!!!!!!!

This kind of thing exemplifies the saying "nurses eat their young". I'm sorry you had to go through this.:balloons: Thank you for becoming a nurse.

ahsweeney · Apr 21, 2004

Wow! Glad to read that I'm not the only one who has made a mistake or two. I've always known that, but you always feel so alone when you do make a mistake. One way I have tried to prevent a medication calculation error is to double check my math not only with a co-worker, but with the pharmacy. In the hospital where I used to work, they were very good with me, especially when I would call down there and ask, "Is this the stupid question department?" They would laugh and say "Hi Alison, what do you want to check". I figure that yes, both departments are busy, but we all would rather spend a minute or two to double check than spend hours filling out reports, etc. Besides, their job is to do those calculation day after day after day. They can crunch those numbers with more confidence that I ever could. The previous advice about admitting the error/mistake quickly is the best. For the most part, you won't get into that much trouble.

cannoli · Apr 21, 2004

I am fixing to graduate LPN and yesterday I was doing a clinical on the med/surg floor. My patient, a 42 yof had an iv in her left hand. Of course, most pt.'s that I have seen myself are afraid to use the hand with the iv and have it propped on the pillow. This one did also. Her fingers were swollen a little but not at the iv site or below below the site. There was good blood return and everything was fine. My clinical instructor went to check it for me to verify because the pt. kept saying she was worried because of the slight edema in her fingers. She explained to the pt., just as I had, that the swelling was because of lack of use and keeping it propped up.
About 10 minutes later, the RN in charge went to give the pt. her meds, demerol and phenergan iv, pt. told her she was worried about it. After RN gave her the meds, she proceeded to tell the pt. that the iv was out and that I was "just a student and didn't know what I was talking about" and changed the iv to the right hand. I didn't have the RN tell me what happened, I had the pt. who very quickly informed me that since I didn't know what I was doing, she didn't want a student if they couldn't tell what was going on.
My clinical instructor and myself went to the RN to ask about what happened, and I apologized for not "recognizing" and infiltration just to be told that I was right in the first place, the iv was fine, there was good blood return, and she was just pacifying the pt. She also said it was easier to tell the pt. that I just didn't know enough yet and that I couldn't tell what was going on. So, how do you cope with that type of thing? HELP!!!!!!!!!!!!!!!!!!

I think it was inappropriate for the RN to say that about you to the patient, particularly since she agreed that the site was fine; even if it wasn't it was still inappropriate, she could have addressed it without putting down someone else and destroying the patient's confidence in her caregiver.

If the RN wanted to "pacify" the patient, she could have restarted the IV without that type of commentary.

Don't let the turkeys get you down!

poopsiebear · Apr 21, 2004

My worst mistake ...

I work in the OR and occasionally, our patients have local anesthesia for their procedures. I made the mistake of not posting the "Patient is awake" sign on the door while the patient is having a bilateral orchiectomy. One of my friends came to my room to say hi. She looked around to see what case I was doing. Then all of a sudden, she blurted out, "Is it OK for men to live without their balls???" The room got deadly silent and after I whispered to my friend that my patient is awake, she quickly slipped out of the OR.

Tweety, BSN, RN · Apr 21, 2004

My worst mistake ...
I work in the OR and occasionally, our patients have local anesthesia for their procedures. I made the mistake of not posting the "Patient is awake" sign on the door while the patient is having a bilateral orchiectomy. One of my friends came to my room to say hi. She looked around to see what case I was doing. Then all of a sudden, she blurted out, "Is it OK for men to live without their balls???" The room got deadly silent and after I whispered to my friend that my patient is awake, she quickly slipped out of the OR.

OMG. That wasn't a mistake. That's one of life's most embarrasing moments. :rotfl:

powel_44 · Apr 22, 2004

Well. you will not be held liable for those actions you have done. The clinical instructor will be, she must supervise her students on all activities/procedures to be carried out by her students. Here on Philippines(based on books), if the student committed a mistakes, the clinical will answer all the possible liabilities.

But good thing, it never happened to you CI.

actually, my worst mistake to date was pretty similar to yours, mwcia12... it was my 1st semester of my RN course and i was looking after an elderly gentleman who was due for a transfusion... we were waiting on the blood to come up from the lab and the hospital's policy was that students could not hang blood, so i went to lunch... while i was at lunch, though, the blood arrived and the RN i was working under had hung it... but as soon as she had hung it, she went to lunch as well and left the RPN in charge of monitoring the patient for a transfusion reaction...
so, i get back from lunch about 30 minutes later and i asked the RPN for report and she said that she had checked his vitals and everything appeared to be fine... so i go into the room and do the classic mistake of focusing on the lines/machines hooked up to the patient instead of really assessing him... i stupidly overlooked assessing the site, but i asked the patient if he had any complaints or pain and he said no...
well, 10 minutes later, the patient's son comes out to the desk where i was charting to find me... he said the patient's arm was really hurting and it looked bruised... and my first thought was "crap, it infiltrated!"... sure enough, it had... the poor man had about half a unit of blood in his tiny little arm... it just looked horrible... so i stopped the infusion, elevated the patient's arm on a pillow and called my clinical instructor... my instructor was pretty cool about it and we applied warm compresses (as per hospital policy) to the site and restarted the blood in his other arm... we explained everything to the patient and his family and they were really understanding about it all... i felt SO bad...
to make matters worse, the RPN totally flipped on me saying that i was negligent because i was responsible for the blood, not her... i think, in hindsight, that she was worried that the mistake would come back on her because she was responsible for monitoring it while the RN was away, and the half a unit would have started infiltrating before the last 10 minutes that i returned to the floor and checked the patient... but, of course, being a student i felt like i had screwed up royally... i think that was the only time i ever contemplated quitting the program...
anyway, i feel pretty lucky that it was my biggest mistake to date because there definitely are a lot worse things that could happen... but you can bet to this day, when i do an assessment, i start with the patient and work my way back to their lines rather than focusing on the pumps anymore!
beth

powel_44 · Apr 22, 2004

:uhoh21: the greatest pain that i ever seen in hospital is the pain felt by the mother seeing her newborn child dying and hungering for life, and finally seeing her newborn dead. i May not made a mistake but the personnel did. The child already clinging for breath. I notified the nurse and nurse notified the doctor. THe doctor came too late. Then he is too late to revive the child. The baby had already jitteriness and having spasm all over the body, and epineprhine was injected. But no effects occur. THen the doctor intubated but still no impprovements. Then finally, CPR was employed and furtherly no improvements. THe mother witness all the suffering of her baby until death. The mother was crying. I feel guilty about it, if only i were a doctor with knowledge and skills i will do to help the infant in order to ease the pain of the mother. i interviewed her, she said it is just like im dead.

I had an IV infiltrate on an infant once. I could see the site through the window, but didn't want to even go in the room to touch her because she had been so hard to settle, and it was a brand new site, so I assumed it was OK. After seeing that poor childs arm after 2 hours I will never assume anything again. It must have been excruciatingly painful.

sorry for wrong grammar.

Tweety, BSN, RN · Apr 22, 2004

Well. you will not be held liable for those actions you have done. The clinical instructor will be, she must supervise her students on all activities/procedures to be carried out by her students. Here on Philippines(based on books), if the student committed a mistakes, the clinical will answer all the possible liabilities.
But good thing, it never happened to you CI.

While this may be true, they can still kick you out of nursing school for your errors. :)