Worst Mistake

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    Today at work we were talking about the various mistakes we have made. Thankfully I don’t think I have ever killed anyone I didn’t mean to, but I have made a couple pretty stupid mistakes in my career. What is the worst mistake you have made as a nurse? If you don’t want to rat on yourself for fear of getting in trouble, what is the worst mistake “your coworker” has ever made?

    To get things started, I have given a Dopamine bolus briefly, instead of the NS. I have sent someone home with a homepack of Ativan instead of T3s, and worst yet, I have dated a coworker.

    Profile photo of MILPN80

    As a newly licensed nurse on a pediatric unit that also cared for overflow Med-Surg patients, I took the fully oriented lady’s meds to her on schedule. She was eating dinner and asked if she could take them when she finished eating and I said yes. My mistake: I forgot – just forgot – to return to see if she actually took them……..and then I received a phone call at home at 2 AM. when the meds were discovered by the next nurse to care for the lady.

    Thankfully, the patient suffered NO ill effects at all, and rightfully, I was written up for a medication error. Got some good counseling from my clinical manager, too…whew – I was SO glad the patient was okay!!!

    Profile photo of clong1212

    I was new to home hospice nursing, about 3-4 mos in. I was PRN at the time. I was asked to go to a patient’s home (who was in a pain crisis) for another nurse who had gotten new orders to increase the patient’s subcutaneous pain pump. I had not yet had the opportunity to work with the pumps. The nurse gave me the following instructions increase the pump to 3ml/hr and bolus to stay the same. When I got there (first, I had a new car, the patient’s home was in a pretty steep valley between two hills and it had been raining.), I parked my car on the very steep driveway and went in. The patient was in the back room, writhing. I gave him a bolus, then got to work. The pump was set in mgs rather than mls, so I figured out how to reprogram the entire pump (which was ALWAYS programmed by the pharmacy that it came from). I waited until the patient was comfortable and went to talk to the family. I went out to my car and the social worker was pulling in. I said my hello and popped my car into reverse. It wouldn’t go ANYWHERE. I looked down into the yard and it looked like previous people had driven down into a flat area and turned around to drive up out of the hill, so I followed suit. Well, I got stuck on the hill. The patient’s wife and sister came out with the social worker and started pushing. Still could not get out. DUG A HOLE into their lawn. Finally, the sister said “it’s almost like the emergency brake is on.” OMG. I felt like the biggest dummy. So after all of that horrifying mess, that night at about 8pm, I get a call from my director. She was in bit of a panic. She asked me to describe EXACTLY what happened. I started to tell her about re-programming the pump. She said that the orders were actually for 3mg/hr NOT 3ml/hr. (Please keep in mind that this is a HIGHLY concentrated bag of morphine. I think it was 10:1. I immediately began crying and freaking out (I am getting chest tightness just re-living it.). My boss reassured me that the pt was fine, that the on call nurse had been called out b/c of the SQ site swelling (Meant to take no more than a total of 2ML/hr). The family had told the on call nurse that the patient had not been that comfortable since receiving his terminal diagnosis. The family never knew. I had to go into the main office and meet with the CNO and get written up (only for CYA reasons). The patient lived another week and a half, so I didn’t kill him, but that was the worst mistake of my nursing career. Needless to say, after that, if another nurse asked me to go make a visit to make any changes, I followed up with both the pharmacy and the written order!

    Profile photo of ella5850

    gave wrong meds for hypertension and blood sugar control to someone who did not need them at all….told my manager and the Doctor. No one was hurt because I told on myself and the patent was monitored appropriately. Much more careful now.

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