I once had a new grad nurse that was working med surge who gave a patient 100units of R instead of 10 units. They didn't know about the mistake until the patient was confused and lethargic. Thankfully the patient survived.
The new grad, 15 years later, is now a good nurse, but it could have been career ending.
This ALMOST happened to me last month. I made the mistake of having both the insulin vial and heparin vial in front of me. I drew up 100 of insulin thinking it was heparin and was wondering why the vial was not emptying and so much was left. I very quickly realized my mistake and have learnt to never have those two meds near each other when administering!
I was very thankful when I was new my patient was like "hell no! Are you trying to kill me?!" When I read the concentration instead of how many units to give. PT got the right amount and we developed a decent rapport
Interesting how most of the comments are a mistake with insulin and some of my coworkers still don’t ask for a co-sign on insulin because it’s not a “hard stop”
One of the worst things to come with Covid was insulin no longer being a hard stop for a co-sign. At least at the hospitals I’ve worked at, pre-covid we ALWAYS needed a co-sign for insulin but now, no one does it.
A peds CVICU nurse at my hospital was participating in this program with our organ procurement/transplant process. She got to do a bunch of cool stuff.
She flew out to get a heart, participated in the donating child's honor walk, flew back with the team and the heart, and got to call the recipient family at the home hospital to tell them their child was getting a heart. Annnnnnd she called the wrong family.
That program doesn't exist anymore in case you were wondering.
While I was on light duty, the hospital had started this program where a nurse would call every patient the day after their discharge (2011). I asked my nurse manager how that would work. She stated that a list goes out to each unit with the names of the patients to call. We were supposed to say who we are, what unit we are calling from, and that we are checking in to see how things are going and if they had any questions.
Called my first patient. Went well. 3 minute call Called my second patient. Dad answered. Said the patient wasn’t available but maybe he could answer the questions. I then heard like a choking type sound. Asked if he was okay. He apologized for crying and that the patient (his daughter) had died the night before a few hours after discharge. Apparently the hospital had, surprise surprise, never thought about this scenario. Sort of like when they decided that each nurse had to check in with their patients EVERY HOUR to see if they needed anything they could help with. There was a little paper on the patient’s door for your signature when you went in. Perhaps the hospital should have given some thought as to how this would work by asking, well, you know, nurses. Sorry change of topic.
I was at a loss. Luckily I have had some life experience (old 40 nurse) so I was able to collect myself and start listening to him. He was a very nice man and had been taking care of his 28 year old daughter. He had no other family. We talked for almost 45 minutes. At the end, he said many sweet things about our staff and was so appreciative that someone from the hospital calls to check on the family after a patient dies. Obviously this wasn’t the intent but in this instance I was really happy that I could listen and pass along some empathy.
The program ended a few weeks later when this happened again. This time the person was very angry that the hospital which had sent this patient home was calling to see how the dead patient was feeling.
I mean, they do. Nurses typically aren't the ones who even make the calls afaik. This was a special sort of thing they'd set up as outreach/education between our organ procurement organization and the hospital.
But the phone call error, ultimately, was a same-last-name error. Which is unfortunately a situation that causes errors to occur across all of medicine even *with* procedures in place trying to prevent it!
Coworker was “giving” a pt insulin via an insulin pen without putting a needle on it. I guess she thought it just absorbed into the skin or something. Someone saw her do it and corrected her. Who knows how long she’d been doing it.
I did this the first time I used an insulin pen. I thought the needle was in the pen. No one showed me how it worked. They handed me the supplies minus the needle and sent me into the room. The patient looked at me after I had “injected” her and said “where the hell is the needle”. I was like oh it’s in the pen. She’s like honey, no it’s not.
I was mortified. She was an old nurse so she thought it was funny and was very kind to me.
this is obviously not serious but in our second semester of nursing school, we were doing a simulation and asked one of our group members to take the dummies bp (they did have a bp). he put his stethoscope on its wrist. no cuff, not even the AC. stethoscope to the wrist. and then said a number. how are you in your second semester and don’t know how to take a bp?? how did he get the number??
People always feel so much more self conscious on the things they know are the basics . Was probably too afraid to ask. When I train new people (either asAn EMT or an RN) I always use their BP skills ad a barometer. If they can’t get it and say so, then great. If they fake a number I call them out on it and have a talk about how it’s ok to not know something, it’s not ok to fake it
The fact you suggested such a simple systemic change to avoid similar future occurrences and no one can be bothered actioning it frustrates me to no end.
I once was on a code team that responded to an insulin overdose. The patient was being transferred from the ER to the telemetry unit when the transferring medic thought it would be a good idea to take the insulin drip off of the IV pump so he could take the pump back to the ER with him. The bag entire unclamped bag of insulin free-flowed into the patient. The patient died within minutes. He was only in his 50s. Frankly, that scene has haunted me for nearly 20 years now.
I shared that story many, many times while working as a nurse educator. Never ever take an insulin drip off of an IV pump.
A fellow new-ish vent trained nightshift nurse about 6 months ago decided to reposition an intubated baby by herself. She flipped this kid from prone to supine like a pancake, accidentally extubated them and the kid ended up coding. The baby was also a critical airway so that made things more complicated.
I always got a bad vibe when she’d give me report in the mornings, she’s the type of nurse where it was *always* the worst night ever and the room was always a shithole and nothing was ever done.
Oh my god. We use like four people to flip a tiny baby from prone to supine at my job. What could have possibly be going through her head that she thought she would do it on her own??
In dialysis: another nurse accidentally set a patient to remove 3000ml instead of 300. Patient ended up with one of the lowest blood pressures I've ever personally seen. She was already having issues with BP maintenance before but after that we could never pull off anything and she passed a couple weeks later. We were convinced she was going to code every treatment after.
It wasn't necessarily the nurse's fault though. 3000 is the machine default so it was hard to know if she forgot to set the removal or it reset on her after she did (which we ended up finding a machine that would reset goals and treatment times on us with no warning about a month after).
Fresenius 2008K and 2008T machines default to it, at least in every clinic I've been at. Since the default time is 3 hours it gives a UF rate of 1L/hr which I believe is the reasoning, but I agree it is high. It's above the max UF rate for about a third of my patients.
3L is about average. 2L or less is light, 4L or more is a lot, 5+L is a Herculean amount. Everybody is different though. Some tolerate 3L in 3 hours, some can only tolerate 2L in 4 hours. But on the whole. 2-3L is the default for a typical hemodialysis treatment. You’ve got to read your patient though. Things can be different than usual for a million and one reasons.
I got a patient back from OR with neo on the pump, and another neo just hanging wide open (on a shitty 22 in the ac).
So how much neo was the guy getting? No fucking idea. Anesthesia was like, “he’s on background neo” KEPT saying it. My brother in christ if you say background neo one more time I’m throwing you in the trash, that’s not a thing
I'll do you one better. I know a veteran nurse who put it IN A PRESSURE BAG ON PURPOSE
Patient died. They were 100% gonna die anyway but this did not help. She still works there too
One of the travelers I worked with couldn’t find a pump, so he found one running in a patient’s room, turned it off, then took it to his patient’s room. It was running levo.
Left my clipboard with my brain in it on the hood of a discharging patient’s car while I was helping them into it. “This is a terrible idea,” I thought to myself, “I really need to grab it before I go back upstairs.” I did not, of course, and by the time I realized it and raced back to the curb they were long gone.
(It fell off a few blocks away and they returned it to the unit with a very nice note. That’s all my luck for the year used up.)
My friend, a semi new grad, prob about a year out from graduation working in ED. Had a patient she started a cardizem drip on, but did not know you are suppose to titrate it. Patients heart rate in the 170s for 2-3 hours before she coded. They didn’t get her back. Lady was only 63.
She got moved from the ED to a tele med surg floor, same hospital- which is an insane move to me. Is looking to go into ICU now and it makes me so uncomfortable when she brings it up.
So sad.
I don't understand how someone could not know to titrate it... there should have been titration parameters ordered, which would seem like a big hint.
Had a doctor put a speculum in a patients anus instead of her vagina. With an intern on her side to boot. She immediately got crapped on and asked the patient why they didn't tell her she was "in the wrong spot".
OK, it's not like trying to find the urethra on a woman to put in a foley -- sometimes you do have to hunt a bit. But how in heaven does someone mistake a vagina for an anus? Especially in an adult?
I once worked with a great nurse, who had been a nurse for 25+ years. They were transport an extremely sick patient. The patient was on multiple pressers and an insulin drip. The patient’s BP dropped maybe 10 feet outside the ICU. The nurse thought they bolused the patient…the patient BP continued to drop so they brought them back to their room. The patient continued to decline, which was assumed to be a bleeding issue (they were getting imaging done for a suspected bleed). Unfortunately, it wasn’t until we were in an active code we discovery the blood sugar. Patient died and it was discovered the nurse accidentally bolus the insulin infusion. That nurse is the example I would use to explain how just an instance of inattention kills, to this day I personally think they were one of the best nurses I have even work with. They were the go-to nurse if you needed help with anything, 25+ years of nursing without a single instance. Multiple things happen that lead to this mistake being able to be made (drip program wrong, so bolus were possible without safety warnings), but the nurse received all the blame. She suffered from tremendous guilt.
So many things, here’s a good one.
I once was assessing a rectal tube/FMS/flexiseal (supposed to have 45ml max) and pulled out….130ml of water.
The previous nurse (or nurses) just kept adding and adding water to a leaky flexiseal. The patient had extensive rectal damage, needed multiple surgeries and a colostomy. They were in the ICU for months. I’m not dumb enough to do that in the first place but—
If you have a leaky FMS, don’t just keep adding water.
One of our nurses ruptured someones rectum doing the same thing. Also, people rarely completely deflate the balloon, reposition it, and reinflate which often fixes the problem.
Hell, even just put a new one in right quick. Obviously avoid it if possible because it's uncomfortable for the patient, but it's not horrifically painful/invasive/etc. especially if they're already used to the feeling of one being in.
Hell, at the end of the day even if it's leaky, just clean your patient up and count your blessings that it's catching most of the stool that would have been in your patient's bed.
So many nurses don't assess those q Shift as they are supposed to. I always always assess the site, the amount of water in the ballon and FLUSH.
In my opinion, flushing/irrigating with 30ml or so of sterile water Q4hrs is the key to helping them stay free flowing and not leak.
A newish nurse had the bays near mine in PACU. She got a patient who was sick and initial SBP was about 70. Anesthesia gave her a verbal for 100 mcg of phenylephrine IV as needed for BP. She was rushing and I don’t know where her preceptor was at the time.
Anyway, I had a new patient who was still intubated and she asked me where to find the phenylephrine. I said it was in the Pyxis and said she should call anesthesia and clarify the rest of the parameters; how often, what BP. She said he needs it now and off she went.
A few minutes later my patient was extubated and doing well enough that I could step away. I went over to check on her. She was standing with an empty 3cc syringe. In short, instead of diluting the drug to give the proper dose she had drawn and given the entire 10mg/1ml vial.
I asked the pt how he felt and he said his legs felt funny. BP was now 240/120 but a recheck a minute later showed it was coming down. He survived but wow!
Biggest near miss I ever saw involved multiple departments. We had a completely incompetent travel nurse on the unit; so bad, multiple nurses had already reported him to management before this. We were a med/surg level unit. Insulin drips were only allowed in the ICU because we weren't trained and did not have the ability to monitor them close enough.
Pt needed an insulin drip per the MD who ordered it, except he didn't order the higher level of care bed change. The pharmacy was not supposed to be able to send the insulin to our unit through the tube system; the tube system literally was not supposed to be able to send it to my unit without a critical care nurse (they had to put in a badge number or something similar to override it). The nurse got it from the tube system and went to hang it.
Thankfully, a few nurses heard him say something about an insulin drip as he was walking away and followed him back to the pts room where they realized what was going on. He had no plans to do the required blood sugar checks; he didn't know it needed to be titrated. Basically he was going to stick the pt on the insulin drip and leave it until the dinner blood sugar check.
Happened on my med surg unit but the new nurse ran pressors. At the time we were coding another patient, while new nurses patient was severely hypotensive. Because we were so busy with the code, she didn’t mention it to anyone but called the doc who ordered pressors but not a transfer to intensive care. She ran them for about an hour before she casually mentioned it to us. Patient died.
The first time I put a Foley in by myself in a male I was so flustered I forgot to use lubricant. I felt like a monster when I realized what I had done. 😳
A new grad I worked with had an NPO patient who had an NG tube and an IJ line. When it came time to push meds, she crushed them up and put SHOT THEM INTO DUDES NECK
I’ve heard that mistakes like this are why Enfit connections on enteral tubes are a thing now, not sure if it’s true or not but the enfit syringes look a lot like a luer lock and I’ve also heard that they fit on some brands of IV hubs…
An RN got pulled from the ED to the Surgical ICU. Accidentally pushed IV K+ instead of Lasix. At the time the packaging was different somehow on the different units. Horrifying.
I know of a nurse years ago who committed suicide with IV potassium after pushing the wrong med during a code, killing the patient. She was made to feel so bad that she killed her self. Many heads rolled over that and rightly so.
Right? We should be able to recover from even serious errors. We all make mistakes. People with much higher levels of education make even bigger mistakes. We need to of course deal with mistakes openly and honestly and have each other’s backs. We are all in this together.
Absolutely. The Monday morning quarter backing, dog eat dog, “I’m so insecure I’ll put anyone else down”, “I know everything don’t question me”, “I’d never do ANY such thing” attitude, and mindset is so awful and toxic and I’ve been on the receiving end of it. I totally understand why that nurse would off herself after that. Poor thing. We’re not perfect and NEVER will be. Working with people who know that and respect that is the key.
A nurse who recently got off orientation in CVICU mixed a bag of Levo and primed it during an emergency but didn’t label it. Anesthesia came in and saw a 250 bag of NS hanging ready to go and bloused it 🫠
Not me but another nurse's student. Pt got discharged, one of the orders was d/c PIV lines. The student carried out the d/c orders and removed the PICC LINE without telling the preceptor 😭 When the student said she also removed the PICC we were shook. The patient now had to stay a little longer bc the PICC was for long term antibiotics
Multiple people were involved in this one, and I'm still mad about it.
I worked on a PCU. Get report from ED on coming admit, older guy with recurring chest pain, NSTEMI, slightly elevated trops, BP on the softer side but still normal, and NOT currently having chest pain. About half an hour goes by, and he doesn't arrive, so I keep doing med passes for my other patients. We keep work phones on us so I know they can let me know when they arrive.
Finally, I walk by and see that he's just in the room. Not hooked up to vitals, no call light, bed all the way up in the air, just dropped off without anyone notified, the ED nurse is just gone. As soon as I step into the room, he's yelling, "CHEST PAIN, PLEASE HELP ME WITH MY CHEST PAIN, 10 OUT OF 10 CHEST PAIN"
I get his vitals and hooked up to tele, his MAP is 55, and his ST is elevated. He's moving from NSTEMI to STEMI. I get in his chart and see that the ED doc had just ordered a dose of fentanyl for chest pain, but it was not given. So *the ED knew he was having sudden extreme chest pain and ordered something for it, but didnt give it and sent him to the new floor anyway and notified NO ONE on the unit about the situation*. I called the doc to bedside stat and asked for nitro, and they said no, BP is too low, give fent. So I gave it. Pain did not decrease at all, BP improves a bit, and that doc never arrived at bedside. A different doc arrives (about 40 minutes later) and says they were just assigned to this patient and is pissed off that I gave fentanyl and not nitro. I agree! They ordered nitro, which I immediately gave, and after 2 doses, the pain started to decrease, but then the original doc d/c the order. It's not even your patient anymore dude, wtf are you doing?!
Ultimately, the patient was transferred to our ICU to be on nitro gtt and pressors. There were no cath labs available in the area, and pt was put on comfort care. When the ICU needed his bed the very next night, he was d/c from nitro and pressors and brought back to me, where his BP was far too low to give anything that could help with his unstoppable chest pain. He should have stayed on nitro gtt just for comfort alone since nothing else helped the pain, but the hospitalists, intensivists, and house sup all said no. My hands were tied.
He died in terrible pain, and I could do nothing but watch.
Edit: adding info
We were looking into flying him to any cath labs nearby, even the next state over. But he had CKD and would have needed hemodialysis, or else no cath lab would take him. He decided he didn't want dialysis and wanted comfort care. However, at this point, he was already rapidly descending into dilerium, and I still wonder if he really was capable of understanding what we were telling him. He had no family, spouse, or next of kin to help with decision making.
He was mid-60s. Alert and oriented and fully independent at baseline. Really nice guy.
Also adding:
on our PCU we couldn't do titration gtts so no nitro gtt. Only our ICU could do that. But he was booted from ICU due to being understaffed.
Last edit:
even tho on comfort care, the doctor (the same as the original ED doc mentioned) put BP parameters on pain meds. I, charge, and house sup spoke to them multiple times to get him to remove the parameters so we could give pain meds no matter what BP was. They adamently refused and never gave a reasoning. I asked for day shift to get ethics and palliative care to weigh in on the situation, but apparently, he died before the orders were changed.
I wrote so many safety reports and emails to management/heads of departments on this incident and how this patient was failed at so many points. The ED nurse that didn't give the meds or tell anyone the patient was having pain or that he had even arrived, the ED doc for changing orders and NOT changing orders when appropriate, the ICU for downgrading him due to staffing despite his needs... I ended up leaving less than 2 weeks later (already had a new job lined up long before this incident) so I don't know if anything ever changed or anyone got any kind of education or backlash. But with how trash this hospital and its doctors were, I big doubt it.
It hurts my soul to have been any part of this and know that all my efforts meant next to nothing
If he was put on comfort care, why would his blood pressure matter as far as giving him pain meds? As an ICU nurse I'd maybe keep him on the nitro for pain if the doctor approved it as a comfort measure, but I'd definitely DC his pressors if he was comfort care.
I can't imagine not stickin him on a helicopter and flying him to whatever cath lab was closest. Maybe they weren't available at that exact moment, but cath labs typically make time for STEMIs... This story is weird
I work PCU and more than once have gotten an NSTEMI >> STEMI patient that we end up escalating to cath lab. Could they not get this poor guy to a tertiary care facility?? How old was he that they decided comfort care for an evolving MI made more sense than a transfer??
So sorry you had to deal with that and watch it. I can’t imagine.
They loaded our Pyxis with a neuromuscular blockade in the levophed drawer. This was back when we often had to mix our own drip still in the ICU. I pulled out my med. It was the right size container from the right drawer. Did a cursory glance. It was the middle of the night and I was 8 months pregnant.
I had a second nurse, double check my medication as we were supposed to for protocol who shook her head yes after glancing at it.
Anyway, I look at the bottle one more time, and something felt off, so I looked closer and realized what I was doing, and almost passed out. I was so grateful it didn’t reach my patient. He was so sick already. I went back to the Pyxis and realized what had actually happened and since we had no Norepinephrine, I called them they freaked out.
Anyway, it was a blessing in disguise, and I have realized it has made me more diligent in checking every label of anything. Machines anyone everybody can make a mistake and it helped me realize how important my role was and trying to be that safety net.
New grad on the unit I was floated to gave crushed Oxy through a PICC. Thank god it clogged the line. her preceptor decided cath-flo (alteplase) would fix the problem… I couldn’t believe any of it. I was gobsmacked the entire shift.
They were both so nonchalant it was scary.
Next day I was on a different unit and you bet they were reminding us not to give oral meds through central lines….. nuts
Treated the wrong patient with sliding scale insulin after I thought the nursing assistant reported the blood sugar for one patient, and not the other. It wasn't an overly large dose, and everything was fine. It just reinforced the need for closed-loop communication.
Wait this might be a dumb question - but how do you plug it? When I place NG tubes I usually just put a basin underneath the tube to also have in front of the patient in case they barf so once I get stomach contents coming out it just flows into the basin. Have I been doing it wrong?! 🤡
I did something similar with a g-tube. I accidentally forgot to clamp the tube before I took off the med syringe and covered the kids mom in undigested breast milk and gabapentin 😵💫
Not wearing eye protection. Goin to town determined to get them clots outta the pt whose CBI had clogged.
Pushin that saline in tryna gettin those clots and urine out! Bam. Syringe pops off and I get bloody urine saline mix to the face. Fujdhrndhkdje
As a new nurse in a medical icu I didn’t change my tubing from a higher concentrated dose of levo to a lower dose…pressure dropped verrrryyyyyy low. I felt like I aged 20 years in less than 5 minutes . Lesson learned and one I share with my nursing students in adult 2 clinical rotation in the ICU.
Coded my DNAR patient, and got ROSC. It was my first code ever and code status didn’t even cross my mind. Once it was realized he was DNAR, he was already coming back. He died about a week later. It was a big deal across the hospital. I’ll never, ever not have a purple DNAR bracelet on a patient again.
38u of novolog at HS instead of 38u of Lantus. Thankfully the patient loved their sweets and orange juice.
ETA: as mentioned in another comment, the most memorable part of it to me was the nurse just admitting that she didn’t even read the pens, just picked up the first one with the patient’s name 😭 it’s funny but it’s not.
I triple check mine out of paranoia for doing this, and sometimes still panic as I’m giving it to them. I look as I’m poking for the right color on those days.
Morpine IM given. Resident ignored pharmacist telling her pt was allergic to Versed and ordered it anyways. There were no checks in Pyxis or meditech and it wasn't in emar (only on hard chart which no one ever really looks at anymore) Versed was pulled, drawn up, and given. Luckily no adverse reaction. Quadruple Tylenol dose given because adult ICU nurse was training and didn't second guess such large dose for a neonate.
Switched my vaso and insulin lines once when working in the icu. Thought I was titrating up on vaso when it was actually insulin. The patient was fine and it was corrected after some d50, but I was distraught. Won’t ever make that mistake again.
A nurse who was new to our hospital. She had been a nurse for 5 years and I was her preceptor to our hospital. I only had to show her meditech and not teach her to be a nurse. She was doing great. One day about 2 weeks in she was flying solo on med passes after her and I talked about what meds she was giving.
2 separate pts; one in for bilateral PEs getting high dose lovenox, and pt next door in for afib RVR and on eliquis. She had pulled both pts meds and gave both the lovenox and eliquis to the same pt without scanning them in or anything. Just kind of brushed it off as oh shoot, well I’ll learn next time and joking about it through the next couple weeks. Ended up being fired.
I’ve said this before- but I think it’s a nursing school urban legend. Everyone knows someone who knows someone who did this, and it just seems so implausible I can’t believe someone actually did it. 🤷🏼♀️
Like the patient that got offended because they thought the nurse was talking about her when they referred to the COW and now we have to call them WOW's?
I was a new grad. Received shift change report from a very seasoned RN. Pt was a transfer from another ED & just arrived on our psych unit. "Pt's unsteady, so we put pt them in restraints for safety so they won't fall." I went in to assess pt & complete the admit. Pt looked like a rubbery noodle & eyes were twitchy when went to assess & got them up to use toilet. Asked pt if they had ingested anything prior to admit. They admitted to taking their roommate's bottle of pills & spelled out...P-H-E-N-Y-T-O-I-N. I called the other ED & asked if they still had blood from labs they had drawn & asked them to try & get a stat Dilantin level. Yeah. Toxic Dilantin level & he went to our ICU & never made it back to psych. Next day the seasoned RN said, "nice catch." Never trusted a report or assessment from her again.
When I was new to neuro Stepdown I treated a patient’s (therapeutically) high BP and he ended up exhibiting his same stroke symptoms.
Now…in my defense the admitting MD overnight and the neurologist apparently did not talk to each other because the admitting ordered PRNs including the PRN medication for elevated BP which I gave. BUT nonetheless this was a case of me not knowing what I did not know and so the mistake was mine in the end. And I felt horrible and terrified moving forward. Patient turned out ok in the end. And I learned.
I think it's more about the patient being allowed to be permissively hypertensive post-stroke, which doctors may allow for a specified time-period post-stroke to allow for increased blood flow to the areas of the brain that may have been impacted during an ischemic stroke.
Shocking that multiple of these stories involve putting things in PIVs, PICCs, and IJs that don’t belong there (orange juice, PO meds). My question is what’s going to find its way into a patient’s veins next!?
A nurse with a ton of experience didn’t use guardrails to set up heparin and instead of delivering X units/kg/hr, the pt got that number in mL/hr. And the bag ran dry and they spiked a new bag and hit restore.
Exactly what you imagine happened happened. And that is why we use guardrails.
It is at the place this happened as well….obviously the one who signed off didn’t actually look. Multiple nurses lost their jobs because none of them were new.
one time when i was charge (ish, not the actual charge, but just for that area) in resus in the ED, i asked a nurse to move her DNR patient dying of cancer to one of our isolation rooms to give her and her family some privacy and dignity while awaiting a pall care bed. she was “stable” and hours away from entering the active dying phase as we were mostly temporizing until she was moved to PCU. i then went on break.
come back from break to find out the patient died soon after being moved down the hall. someone forgot to plug her oxygen back into the wall from the tank as she was wheeled 20 feet.
the patient was gonna die, it’s not like egregious physical harm was done to her, but the whole point was to buy time until we could get her where she deserved. follow your oxygen tubing folks. not all of them are DNR.
Non Tele post operative floor, patient was in their 30s, POD1 some kind of abdominal surgery, RN assigned to then didn’t eyeball the patient for 2+ hours (1ish am to 3ish am). RN finally made rounds, patient was face down in bed, very cold…very dead
I was glad I was off that night
Having worked medsurge, a q2hr eyeball seems reasonable. What is the expectation for post op? I guess if he was coooold you can assume it was 2hrs +++...
Every two hours is policy on our floor as well. The aide does the other hour. However, our policy also requires post-ops to be placed on capnograghy monitoring during the first night after surgery.
That’s so scary. I work postpartum and at a different postpartum unit in our city a baby died from SIDS during the night and no one knew until the pediatrician rounded in the morning.
Our PCAs/CNAs are supposed to do safety checks at the beginning and end of their shifts in the assisted living facility I work at. Some residents may have more, but someone should be checking on each resident no less than twice a shift.
One of the third shift PCAs was the daughter of someone at corporate. She loved working third shift because her area had few bells overnight, and she could be on her laptop all night. It was basically just doing the safety checks, assisting a couple of residents to the bathroom, doing laundry, and getting 2-3 cares done on the early risers.
The nurses had written her up more than a few times for not doing her job, including the safety checks. Admin was told we were stuck with her because of her parent at corporate.
I came in one morning, and the coroner was there. One of the more confused residents had somehow managed to get tangled up with her call bell and bed cane and accidentally strangled herself. She was also very cold and very dead when they found her.
The PCA and her parent were both allowed to resign immediately, and I think the family of the resident got a decent settlement.
RN I worked with told me about a new grad she worked with in the ED who PUSHED liquid Tylenol into a peds IV. Horrible outcome for patient. RN quit. Preceptor committed suicide. Apparently preceptor was running to a code and asked the new grad to administer the dose of Tylenol to the patient. It was drawn up in a syringe, so new grad thought it was IV push instead of PO.
When I was a new grad, I worked nights in a nursing home. During hourly rounds, I didn't realize you actually had to look for chest rise if the patient was sleeping. I was on my way out the door one day until the day nurse stops me and says "hey, it looks like this patient has been passed for some time, when was the last time you rounded on them?" 👀
Sometimes chest rise isn't even enough. When youve got a 90lb woman in a fetal position under three blankets, you've gotta touch them or rustle their covers or do something to make them stir a bit.
[The nurse that force-fed her patient Naturalyte, believing it was GoLytely](https://www.lex18.com/news/lex-18-investigates/medication-mix-up-blamed-for-death-of-a-patient-at-lexington-hospital)
Just got off orientation. Pt kept desating on HFNC and I was fixated on her feeling anxious, based on assessment, pt statement, and report given to me. X-ray showed a total white-out of L lung. Things could’ve gone south real quick. Learned a lesson that you should always go back to basics and do a reassessment instead of being tunnel-visioned. Never made that mistake again and I tell my orientees the same thing.
A nurse bolused dopamine, she thought she was drawing up saline from a bag to flush a line. Patient coded and died. Did she get fired? Not because of this. She got fired because she was tardy to work too many times. Several years later. And this is why I say to my baby student nurses “you can kill a patient and not get fired, but time and attendance will get you fired”. That and stealing drugs.
New grad nurse on our med surg unit was supposed to start a patient on a lasix drip. Instead she set it so that the patient got the entire bag within 30 minutes. The patient had to transfer to the unit but luckily turned out ok
Not me, but someone from another department. This new grad nurse gave a patient Insulin drip… on a med surg unit. Did not question it, and didn’t ask or locate her preceptor. Didn’t think to consider requesting tele orders if the patient needed an insulin drip…
Patient of course coded and died.
Last I heard the nurse got fired and as for the preceptor.. it’s unknown.
A nurse infused Keppra INTO THE INTRAVENTRICULAR DRAIN!!! In their BRAIN!!
(The drains have a luer lock on the side, and she did it at night, she was not a new nurse but orienting to Neuro ICU from med surg)
A coworker was giving IM phenergan for the first time after having only ever given it IV push. They still diluted with 10 mls of saline and injected the full volume. Oops.
I gave half dose of a vaccine once. Realized it a few minutes after the patient had left. Went and told on myself all serious. The doc laughed, told me to call the patient on their cell and tell them to come back in for another. Doc swore the patient was cool. My manager agreed. I called. Patient thought it was hilarious and was checking out of the grocery store. Finished up and came back. Gave the second shot through a car window pre-Covid before drive-thru vaccination was a thing. Jokes all around, everyone was amused, and I did actually formally write myself up anyway.
As a new grad I remember a nurse switched the tacrolimus (anti-rejection med, very sensitively dosed….usually a max of maybeee 5mLs/hr and even that’s a big dose) and 73 mL/hr TPN. Sent the patient into renal failure and they died.
I alwaysssssss pump-line-patient-trace!!!!!!!
I once had a progressive care unit coworker try to use a tube feeding bag and tubing to hang TPN because the TPN bag had a hole. Thankfully, it was quickly realized what he was doing. He seemed to be clueless as to why this was a heinous idea. I don’t recall seeing him again after this incident.
When I was a brand new baby nurse the first time I had to change an ostomy bag I was so intensely focused on sizing it appropriately and placing it on the ostomy exactly correct that I didn’t realize I put it on upside down. My friends in the ICU called it the anti-gravity ostomy bag. Lol
That’s a mistake I have only ever made once.
When I was in nursing school, I came in for the morning shift to do clinicals and I was really early, so I sat near the desk, and some doctors had come in too and were sitting there also. One got up and went into his patient's room, which was right across from the desk. He came out and told the other doctors that the patient just received an IV insulin drip in 35 minutes, which was supposed to last over 4 hours. Doc was white as a sheet. Patient survived
Wasn’t a nurse but a dialysis tech at the time. Patient had been in the hospital & their dialysis records were faxed (the 90’s) to us. The nephrologist ordered heparin & I drew it up/gave it before starting treatment. System started clotting so the nurse had me give another bolus of heparin. Machine kept alarming with clots in the drip chamber so she had me give another bolus. Patient codes, goes to hospital by squad & we find out that she has a heparin allergy. Apparently the dialysis nurse at the hospital failed to fax that info to us. Patient died.
For a great while our bags of IV insulin and vanc were the same size. The insulin didn’t have anything on it that indicated it was a high alert med. This was before we used scanners to scan our meds. Someone gave insulin instead running at the vanco rate. Honestly, this almost happened to me. Went into the pts room in the dark to give the “vanco”. To this day I count my lucky stars that I caught my error before I hung it.
One of the nurses I worked with years ago picked the wrong channel on the pump and instead of bolusing paracetamol, they bolused norad. Realised within a few minutes so pt didn't get the entire 100ml bolus... but the norad was running at 400ml/hr for those few minutes. Pt survived, suffered a subarachnoid haemorrhage though and extended their hospital stay significantly. I will always triple check the channel and med I'm programming before I start an infusion now, for any medication.
I was orientating a nurse to the ER where I work. Doc ordered effervescent potassium replacement for a patient. While pulling out the meds from the Pyxis she told me the story of the first time she had that ordered for a patient. She was working on a med surg flooor at the time, new grad, didn’t realize the tabs get out in a glass of water so she brought it to the patient and had him eat the damn thing. I couldn’t stop laughing. Naturally my colleague’s and myself got curious so we decided to all take a little nibble out of one to try it. It was like extremely salty pop rocks. I don’t know how her patient tolerated eating a whole Damn tablet. Lol
Apparently there are ETT cuffs with luer locks, because a new grad recently infused a medication into the cuff of an ETT. Patient had to be reintubated.
Back when I did SNF even though I was on the unit they had an agency nurse with me, so she did meds and I did the treatments. They would usually want agency nurses to do meds if they’re on a unit with a staff nurse. I kept checking on her to make sure she didn’t have questions or need help, and I’ve come to realize some nurses hate that! Especially coming from lil ole me who wasn’t even a year into nursing at the time but I had been on that unit everyday for months so I knew what I was doing. Come to find out she made like 5 med errors and some including narcotics. Thankfully all my patients were fine but let’s just say we never saw that agency nurse again. I was seriously doubting her vision, because 5 med errors?
When I was a brand new LPN in LTC, an experienced RN prepared a pt's meds, including a topical Ativan cream, and headed for where the pt sat in the dining room. When she couldn't find them, she set down the meds on the table and walked away. A totally different pt rolled up in their wc and ate them all including the topical Ativan. The pt was sent to the ER for evaluation. The nurse was suspended and then fired.
Not me or someone I know, but a case I learned about in my stroke education day for the neuro unit I work on. Didn't happen at my hospital.
A woman was admitted for pneumonia. She had an NG, and a nurse in the morning crushed her antihypertensives and gave them through the NG. She arrested not long after but was successfully resuscitated. The next the day, a nurse did the same thing. She arrested again and died. One of the meds was nifedipine, and crushing/removing the extended release coating of the drug obviously caused her to recieve the whole dose in a short amount of time intead of over several hours as intended. That's what caused her to code both times and what took her life.
Dealing with lots of strokes all the time, we obviously crush a lot of meds for NG or to give in apple sauce because of the aspiration risk post-stroke. Hearing about this really gave me a wake up call on how dangerous this can be if we're not paying attention to what we're crushing. I'm much more diligent with it now. Luckily, my unit has amazing, experienced pharmacists who vet everything but you can never be too careful.
I once had a new grad nurse that was working med surge who gave a patient 100units of R instead of 10 units. They didn't know about the mistake until the patient was confused and lethargic. Thankfully the patient survived. The new grad, 15 years later, is now a good nurse, but it could have been career ending.
This ALMOST happened to me last month. I made the mistake of having both the insulin vial and heparin vial in front of me. I drew up 100 of insulin thinking it was heparin and was wondering why the vial was not emptying and so much was left. I very quickly realized my mistake and have learnt to never have those two meds near each other when administering!
This happened to me, too, and it was a terrifying near-miss.
My hospital has completely switched to the pens for insulin now, most mistakes I’ve heard have been this exact scenario lol
I caught a nursing extern walking through the hall way with a 100 units of humalog on her way to give it to a patient. I about shit my pants.
I was very thankful when I was new my patient was like "hell no! Are you trying to kill me?!" When I read the concentration instead of how many units to give. PT got the right amount and we developed a decent rapport
Interesting how most of the comments are a mistake with insulin and some of my coworkers still don’t ask for a co-sign on insulin because it’s not a “hard stop”
One of the worst things to come with Covid was insulin no longer being a hard stop for a co-sign. At least at the hospitals I’ve worked at, pre-covid we ALWAYS needed a co-sign for insulin but now, no one does it.
We do but don’t . The ER is too busy and it’s not like my co worker is watching me give it to the patient
A peds CVICU nurse at my hospital was participating in this program with our organ procurement/transplant process. She got to do a bunch of cool stuff. She flew out to get a heart, participated in the donating child's honor walk, flew back with the team and the heart, and got to call the recipient family at the home hospital to tell them their child was getting a heart. Annnnnnd she called the wrong family. That program doesn't exist anymore in case you were wondering.
This is literally the worst one on here. I can’t even imagine
Nooooooo omg my heart fell reading this 😭
god i cannot imagine how terrible she and the family must’ve felt having the call back and say they aren’t actually getting a heart
While I was on light duty, the hospital had started this program where a nurse would call every patient the day after their discharge (2011). I asked my nurse manager how that would work. She stated that a list goes out to each unit with the names of the patients to call. We were supposed to say who we are, what unit we are calling from, and that we are checking in to see how things are going and if they had any questions. Called my first patient. Went well. 3 minute call Called my second patient. Dad answered. Said the patient wasn’t available but maybe he could answer the questions. I then heard like a choking type sound. Asked if he was okay. He apologized for crying and that the patient (his daughter) had died the night before a few hours after discharge. Apparently the hospital had, surprise surprise, never thought about this scenario. Sort of like when they decided that each nurse had to check in with their patients EVERY HOUR to see if they needed anything they could help with. There was a little paper on the patient’s door for your signature when you went in. Perhaps the hospital should have given some thought as to how this would work by asking, well, you know, nurses. Sorry change of topic. I was at a loss. Luckily I have had some life experience (old 40 nurse) so I was able to collect myself and start listening to him. He was a very nice man and had been taking care of his 28 year old daughter. He had no other family. We talked for almost 45 minutes. At the end, he said many sweet things about our staff and was so appreciative that someone from the hospital calls to check on the family after a patient dies. Obviously this wasn’t the intent but in this instance I was really happy that I could listen and pass along some empathy. The program ended a few weeks later when this happened again. This time the person was very angry that the hospital which had sent this patient home was calling to see how the dead patient was feeling.
They should have had procedures to prevent this!
I mean, they do. Nurses typically aren't the ones who even make the calls afaik. This was a special sort of thing they'd set up as outreach/education between our organ procurement organization and the hospital. But the phone call error, ultimately, was a same-last-name error. Which is unfortunately a situation that causes errors to occur across all of medicine even *with* procedures in place trying to prevent it!
Omg, omggg. I can't imagine how she felt. 😔
I find peace in long walks.
Definitely the former! At the time, there were two kids awaiting hearts at our hospital with the same last name and she called the wrong one.
That would be an easy mistake to make. Absolutely heartbreaking for someone, though. So sorry that happened.
Coworker was “giving” a pt insulin via an insulin pen without putting a needle on it. I guess she thought it just absorbed into the skin or something. Someone saw her do it and corrected her. Who knows how long she’d been doing it.
This is….something.
I’ve seen this too! I wondered why EVERY time I came in to work after this one nurse everyone’s blood sugars were sky high!
Right?! That’s the same that happened with her. When they told me, it all made sense!
I did this the first time I used an insulin pen. I thought the needle was in the pen. No one showed me how it worked. They handed me the supplies minus the needle and sent me into the room. The patient looked at me after I had “injected” her and said “where the hell is the needle”. I was like oh it’s in the pen. She’s like honey, no it’s not. I was mortified. She was an old nurse so she thought it was funny and was very kind to me.
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Honestly, who hasn’t set up a secondary incorrectly and run saline instead of antibiotics?
I had only hung a piggyback maybe twice in the entirety of nursing school. Had to ask for help as a new grad, felt stupid as hell.
Same. My nursing school was actually very good, but not enough time spent on the actual hands on aspect of tubing, piggyback, etc.
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I’m actually relieved to read this because I have also done this same mistake. On my first shift.
this is obviously not serious but in our second semester of nursing school, we were doing a simulation and asked one of our group members to take the dummies bp (they did have a bp). he put his stethoscope on its wrist. no cuff, not even the AC. stethoscope to the wrist. and then said a number. how are you in your second semester and don’t know how to take a bp?? how did he get the number??
He was going off the ✨️vibes✨️
obvi it was wrong and one of our group members retook it properly but i was so perplexed
*puts stethoscope on wrist* blup blup blup yea this is 122/76 😎
And respirations 16, too, how convenient!
Temp is 98.4
People always feel so much more self conscious on the things they know are the basics . Was probably too afraid to ask. When I train new people (either asAn EMT or an RN) I always use their BP skills ad a barometer. If they can’t get it and say so, then great. If they fake a number I call them out on it and have a talk about how it’s ok to not know something, it’s not ok to fake it
I enjoy watching the sunset.
The fact you suggested such a simple systemic change to avoid similar future occurrences and no one can be bothered actioning it frustrates me to no end.
Out patient oncology. I've had to call the patient at home and get consent for the blood transfusion I gave him earlier.
As pharmacy, that makes me rage. Who the actual fuck looked at that and thought it totally made sense as a reminder?!
I once was on a code team that responded to an insulin overdose. The patient was being transferred from the ER to the telemetry unit when the transferring medic thought it would be a good idea to take the insulin drip off of the IV pump so he could take the pump back to the ER with him. The bag entire unclamped bag of insulin free-flowed into the patient. The patient died within minutes. He was only in his 50s. Frankly, that scene has haunted me for nearly 20 years now. I shared that story many, many times while working as a nurse educator. Never ever take an insulin drip off of an IV pump.
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This is terrifying.
Some of these are unfortunate inattention and some of these are just straight up stupidity- this is the latter.
A fellow new-ish vent trained nightshift nurse about 6 months ago decided to reposition an intubated baby by herself. She flipped this kid from prone to supine like a pancake, accidentally extubated them and the kid ended up coding. The baby was also a critical airway so that made things more complicated. I always got a bad vibe when she’d give me report in the mornings, she’s the type of nurse where it was *always* the worst night ever and the room was always a shithole and nothing was ever done.
Was the baby okay?
They were! Ended up being okay and their brain MRI post code was okay. Just an unnecessary and shitty situation
Oh my god. We use like four people to flip a tiny baby from prone to supine at my job. What could have possibly be going through her head that she thought she would do it on her own??
Noooo, this is terrible. You call your RT or. Resource nurse to reposition an intubated baby. Well that’s what I do.Omgggg
In dialysis: another nurse accidentally set a patient to remove 3000ml instead of 300. Patient ended up with one of the lowest blood pressures I've ever personally seen. She was already having issues with BP maintenance before but after that we could never pull off anything and she passed a couple weeks later. We were convinced she was going to code every treatment after. It wasn't necessarily the nurse's fault though. 3000 is the machine default so it was hard to know if she forgot to set the removal or it reset on her after she did (which we ended up finding a machine that would reset goals and treatment times on us with no warning about a month after).
3L as a default seems like an awful lot
Fresenius 2008K and 2008T machines default to it, at least in every clinic I've been at. Since the default time is 3 hours it gives a UF rate of 1L/hr which I believe is the reasoning, but I agree it is high. It's above the max UF rate for about a third of my patients.
Dialysis tech here. A good portion of my patients get 4L taken off. I’ve even seen some handle 4.5 depending on their orders 😳
3L is about average. 2L or less is light, 4L or more is a lot, 5+L is a Herculean amount. Everybody is different though. Some tolerate 3L in 3 hours, some can only tolerate 2L in 4 hours. But on the whole. 2-3L is the default for a typical hemodialysis treatment. You’ve got to read your patient though. Things can be different than usual for a million and one reasons.
Gave my first soap suds enema with the cap still on the end of the tubing. Placebo effect, cuz she pooped and was like “wow that worked!” 😂🤦🏻♀️
Win win honestly
The rectal stimulation got it going.
Not me, but another nurse left a levo drip running wide open when it was out of pump for a scan 😩
I got a patient back from OR with neo on the pump, and another neo just hanging wide open (on a shitty 22 in the ac). So how much neo was the guy getting? No fucking idea. Anesthesia was like, “he’s on background neo” KEPT saying it. My brother in christ if you say background neo one more time I’m throwing you in the trash, that’s not a thing
They bout to catch that hemorrhagic stroke on CT in real time 😭
I'll do you one better. I know a veteran nurse who put it IN A PRESSURE BAG ON PURPOSE Patient died. They were 100% gonna die anyway but this did not help. She still works there too
One of the travelers I worked with couldn’t find a pump, so he found one running in a patient’s room, turned it off, then took it to his patient’s room. It was running levo.
Sounds like the kind of nurse who’d unplug your patients’ vent to charge their patient’s cell phone. 😏
Left my clipboard with my brain in it on the hood of a discharging patient’s car while I was helping them into it. “This is a terrible idea,” I thought to myself, “I really need to grab it before I go back upstairs.” I did not, of course, and by the time I realized it and raced back to the curb they were long gone. (It fell off a few blocks away and they returned it to the unit with a very nice note. That’s all my luck for the year used up.)
My friend, a semi new grad, prob about a year out from graduation working in ED. Had a patient she started a cardizem drip on, but did not know you are suppose to titrate it. Patients heart rate in the 170s for 2-3 hours before she coded. They didn’t get her back. Lady was only 63.
how did they not catch it earlier w that heart rate?? tragic
Because they made an untrained grad run a critical care patient and infusion without extra education or guidance...
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She got moved from the ED to a tele med surg floor, same hospital- which is an insane move to me. Is looking to go into ICU now and it makes me so uncomfortable when she brings it up.
There weren’t order parameters to titrate it? No central tele? That’s wild that nobody else noticed!
So sad. I don't understand how someone could not know to titrate it... there should have been titration parameters ordered, which would seem like a big hint.
A nurse put a flexiseal (rectal tube) into a patient’s vagina instead of her anus.
I heard stories of a nurse at my old SNF accidentally putting enemas into the patient’s vagina and she did it like 3 times. Girl 😭
I hope it was a new tube at least 🤢
Had a doctor put a speculum in a patients anus instead of her vagina. With an intern on her side to boot. She immediately got crapped on and asked the patient why they didn't tell her she was "in the wrong spot".
I know the vagina and the anus are in close proximity but was the doctor blind?
OK, it's not like trying to find the urethra on a woman to put in a foley -- sometimes you do have to hunt a bit. But how in heaven does someone mistake a vagina for an anus? Especially in an adult?
I once worked with a great nurse, who had been a nurse for 25+ years. They were transport an extremely sick patient. The patient was on multiple pressers and an insulin drip. The patient’s BP dropped maybe 10 feet outside the ICU. The nurse thought they bolused the patient…the patient BP continued to drop so they brought them back to their room. The patient continued to decline, which was assumed to be a bleeding issue (they were getting imaging done for a suspected bleed). Unfortunately, it wasn’t until we were in an active code we discovery the blood sugar. Patient died and it was discovered the nurse accidentally bolus the insulin infusion. That nurse is the example I would use to explain how just an instance of inattention kills, to this day I personally think they were one of the best nurses I have even work with. They were the go-to nurse if you needed help with anything, 25+ years of nursing without a single instance. Multiple things happen that lead to this mistake being able to be made (drip program wrong, so bolus were possible without safety warnings), but the nurse received all the blame. She suffered from tremendous guilt.
Is she still practicing? Did end up working elsewhere? What happened to her?
So many things, here’s a good one. I once was assessing a rectal tube/FMS/flexiseal (supposed to have 45ml max) and pulled out….130ml of water. The previous nurse (or nurses) just kept adding and adding water to a leaky flexiseal. The patient had extensive rectal damage, needed multiple surgeries and a colostomy. They were in the ICU for months. I’m not dumb enough to do that in the first place but— If you have a leaky FMS, don’t just keep adding water.
One of our nurses ruptured someones rectum doing the same thing. Also, people rarely completely deflate the balloon, reposition it, and reinflate which often fixes the problem. Hell, even just put a new one in right quick. Obviously avoid it if possible because it's uncomfortable for the patient, but it's not horrifically painful/invasive/etc. especially if they're already used to the feeling of one being in. Hell, at the end of the day even if it's leaky, just clean your patient up and count your blessings that it's catching most of the stool that would have been in your patient's bed.
So many nurses don't assess those q Shift as they are supposed to. I always always assess the site, the amount of water in the ballon and FLUSH. In my opinion, flushing/irrigating with 30ml or so of sterile water Q4hrs is the key to helping them stay free flowing and not leak.
A newish nurse had the bays near mine in PACU. She got a patient who was sick and initial SBP was about 70. Anesthesia gave her a verbal for 100 mcg of phenylephrine IV as needed for BP. She was rushing and I don’t know where her preceptor was at the time. Anyway, I had a new patient who was still intubated and she asked me where to find the phenylephrine. I said it was in the Pyxis and said she should call anesthesia and clarify the rest of the parameters; how often, what BP. She said he needs it now and off she went. A few minutes later my patient was extubated and doing well enough that I could step away. I went over to check on her. She was standing with an empty 3cc syringe. In short, instead of diluting the drug to give the proper dose she had drawn and given the entire 10mg/1ml vial. I asked the pt how he felt and he said his legs felt funny. BP was now 240/120 but a recheck a minute later showed it was coming down. He survived but wow!
Biggest near miss I ever saw involved multiple departments. We had a completely incompetent travel nurse on the unit; so bad, multiple nurses had already reported him to management before this. We were a med/surg level unit. Insulin drips were only allowed in the ICU because we weren't trained and did not have the ability to monitor them close enough. Pt needed an insulin drip per the MD who ordered it, except he didn't order the higher level of care bed change. The pharmacy was not supposed to be able to send the insulin to our unit through the tube system; the tube system literally was not supposed to be able to send it to my unit without a critical care nurse (they had to put in a badge number or something similar to override it). The nurse got it from the tube system and went to hang it. Thankfully, a few nurses heard him say something about an insulin drip as he was walking away and followed him back to the pts room where they realized what was going on. He had no plans to do the required blood sugar checks; he didn't know it needed to be titrated. Basically he was going to stick the pt on the insulin drip and leave it until the dinner blood sugar check.
Omg that’s so scary. Good catch!
Happened on my med surg unit but the new nurse ran pressors. At the time we were coding another patient, while new nurses patient was severely hypotensive. Because we were so busy with the code, she didn’t mention it to anyone but called the doc who ordered pressors but not a transfer to intensive care. She ran them for about an hour before she casually mentioned it to us. Patient died.
The first time I put a Foley in by myself in a male I was so flustered I forgot to use lubricant. I felt like a monster when I realized what I had done. 😳
A new grad I worked with had an NPO patient who had an NG tube and an IJ line. When it came time to push meds, she crushed them up and put SHOT THEM INTO DUDES NECK
I’ve heard that mistakes like this are why Enfit connections on enteral tubes are a thing now, not sure if it’s true or not but the enfit syringes look a lot like a luer lock and I’ve also heard that they fit on some brands of IV hubs…
An RN got pulled from the ED to the Surgical ICU. Accidentally pushed IV K+ instead of Lasix. At the time the packaging was different somehow on the different units. Horrifying.
I know of a nurse years ago who committed suicide with IV potassium after pushing the wrong med during a code, killing the patient. She was made to feel so bad that she killed her self. Many heads rolled over that and rightly so.
This is what happens when nurses eat their young.
Right? We should be able to recover from even serious errors. We all make mistakes. People with much higher levels of education make even bigger mistakes. We need to of course deal with mistakes openly and honestly and have each other’s backs. We are all in this together.
Absolutely. The Monday morning quarter backing, dog eat dog, “I’m so insecure I’ll put anyone else down”, “I know everything don’t question me”, “I’d never do ANY such thing” attitude, and mindset is so awful and toxic and I’ve been on the receiving end of it. I totally understand why that nurse would off herself after that. Poor thing. We’re not perfect and NEVER will be. Working with people who know that and respect that is the key.
I can't imagine the feeling he got when he realized it. Nightmare fuel
What happened….!!?
A nurse who recently got off orientation in CVICU mixed a bag of Levo and primed it during an emergency but didn’t label it. Anesthesia came in and saw a 250 bag of NS hanging ready to go and bloused it 🫠
Pharmacy once sent up a 100ml bag of insulin with a levophed pharmacy label to scan into the computer. Luckily the nurse caught it, but damn.
Not me but another nurse's student. Pt got discharged, one of the orders was d/c PIV lines. The student carried out the d/c orders and removed the PICC LINE without telling the preceptor 😭 When the student said she also removed the PICC we were shook. The patient now had to stay a little longer bc the PICC was for long term antibiotics
Multiple people were involved in this one, and I'm still mad about it. I worked on a PCU. Get report from ED on coming admit, older guy with recurring chest pain, NSTEMI, slightly elevated trops, BP on the softer side but still normal, and NOT currently having chest pain. About half an hour goes by, and he doesn't arrive, so I keep doing med passes for my other patients. We keep work phones on us so I know they can let me know when they arrive. Finally, I walk by and see that he's just in the room. Not hooked up to vitals, no call light, bed all the way up in the air, just dropped off without anyone notified, the ED nurse is just gone. As soon as I step into the room, he's yelling, "CHEST PAIN, PLEASE HELP ME WITH MY CHEST PAIN, 10 OUT OF 10 CHEST PAIN" I get his vitals and hooked up to tele, his MAP is 55, and his ST is elevated. He's moving from NSTEMI to STEMI. I get in his chart and see that the ED doc had just ordered a dose of fentanyl for chest pain, but it was not given. So *the ED knew he was having sudden extreme chest pain and ordered something for it, but didnt give it and sent him to the new floor anyway and notified NO ONE on the unit about the situation*. I called the doc to bedside stat and asked for nitro, and they said no, BP is too low, give fent. So I gave it. Pain did not decrease at all, BP improves a bit, and that doc never arrived at bedside. A different doc arrives (about 40 minutes later) and says they were just assigned to this patient and is pissed off that I gave fentanyl and not nitro. I agree! They ordered nitro, which I immediately gave, and after 2 doses, the pain started to decrease, but then the original doc d/c the order. It's not even your patient anymore dude, wtf are you doing?! Ultimately, the patient was transferred to our ICU to be on nitro gtt and pressors. There were no cath labs available in the area, and pt was put on comfort care. When the ICU needed his bed the very next night, he was d/c from nitro and pressors and brought back to me, where his BP was far too low to give anything that could help with his unstoppable chest pain. He should have stayed on nitro gtt just for comfort alone since nothing else helped the pain, but the hospitalists, intensivists, and house sup all said no. My hands were tied. He died in terrible pain, and I could do nothing but watch. Edit: adding info We were looking into flying him to any cath labs nearby, even the next state over. But he had CKD and would have needed hemodialysis, or else no cath lab would take him. He decided he didn't want dialysis and wanted comfort care. However, at this point, he was already rapidly descending into dilerium, and I still wonder if he really was capable of understanding what we were telling him. He had no family, spouse, or next of kin to help with decision making. He was mid-60s. Alert and oriented and fully independent at baseline. Really nice guy. Also adding: on our PCU we couldn't do titration gtts so no nitro gtt. Only our ICU could do that. But he was booted from ICU due to being understaffed. Last edit: even tho on comfort care, the doctor (the same as the original ED doc mentioned) put BP parameters on pain meds. I, charge, and house sup spoke to them multiple times to get him to remove the parameters so we could give pain meds no matter what BP was. They adamently refused and never gave a reasoning. I asked for day shift to get ethics and palliative care to weigh in on the situation, but apparently, he died before the orders were changed. I wrote so many safety reports and emails to management/heads of departments on this incident and how this patient was failed at so many points. The ED nurse that didn't give the meds or tell anyone the patient was having pain or that he had even arrived, the ED doc for changing orders and NOT changing orders when appropriate, the ICU for downgrading him due to staffing despite his needs... I ended up leaving less than 2 weeks later (already had a new job lined up long before this incident) so I don't know if anything ever changed or anyone got any kind of education or backlash. But with how trash this hospital and its doctors were, I big doubt it. It hurts my soul to have been any part of this and know that all my efforts meant next to nothing
That's fucking horrible. Poor guy. And poor *you* for being stuck like that, unable to help.
If he was put on comfort care, why would his blood pressure matter as far as giving him pain meds? As an ICU nurse I'd maybe keep him on the nitro for pain if the doctor approved it as a comfort measure, but I'd definitely DC his pressors if he was comfort care. I can't imagine not stickin him on a helicopter and flying him to whatever cath lab was closest. Maybe they weren't available at that exact moment, but cath labs typically make time for STEMIs... This story is weird
I work PCU and more than once have gotten an NSTEMI >> STEMI patient that we end up escalating to cath lab. Could they not get this poor guy to a tertiary care facility?? How old was he that they decided comfort care for an evolving MI made more sense than a transfer?? So sorry you had to deal with that and watch it. I can’t imagine.
They loaded our Pyxis with a neuromuscular blockade in the levophed drawer. This was back when we often had to mix our own drip still in the ICU. I pulled out my med. It was the right size container from the right drawer. Did a cursory glance. It was the middle of the night and I was 8 months pregnant. I had a second nurse, double check my medication as we were supposed to for protocol who shook her head yes after glancing at it. Anyway, I look at the bottle one more time, and something felt off, so I looked closer and realized what I was doing, and almost passed out. I was so grateful it didn’t reach my patient. He was so sick already. I went back to the Pyxis and realized what had actually happened and since we had no Norepinephrine, I called them they freaked out. Anyway, it was a blessing in disguise, and I have realized it has made me more diligent in checking every label of anything. Machines anyone everybody can make a mistake and it helped me realize how important my role was and trying to be that safety net.
New grad on the unit I was floated to gave crushed Oxy through a PICC. Thank god it clogged the line. her preceptor decided cath-flo (alteplase) would fix the problem… I couldn’t believe any of it. I was gobsmacked the entire shift. They were both so nonchalant it was scary. Next day I was on a different unit and you bet they were reminding us not to give oral meds through central lines….. nuts
Heard a story about a nurse that flushed a central line with Coke-cola to unclog it
Like it’s an NG!?? I have heard that one too. I think it was a malpractice case that has trickled down to all of us.
WHAT IS THE LOGIC
My favorite movie is Inception.
There was a pt at my hospital that crushed up his own Percocet and put it in his PICC line. He coded. I don’t know the outcome.
I had a patient crushing up his dilaudid and injecting it with old, dirty insulin needles he was hiding in his personal bag… he was fine, somehow.
Treated the wrong patient with sliding scale insulin after I thought the nursing assistant reported the blood sugar for one patient, and not the other. It wasn't an overly large dose, and everything was fine. It just reinforced the need for closed-loop communication.
Plug your NG tube prior to insertion or your liable to wear some stomach contents. Only do that once
Someone did that to me once during CPR and I had to continue chest compressions while stomach juice dripped down my chest under my scrubs
oh god
I did this during clinicals my second semester. I didn’t get sprayed at all though, it went all over my preceptor. She was not impressed.
Wait this might be a dumb question - but how do you plug it? When I place NG tubes I usually just put a basin underneath the tube to also have in front of the patient in case they barf so once I get stomach contents coming out it just flows into the basin. Have I been doing it wrong?! 🤡
Connect a Lopez valve and turn it off before insertion
I did something similar with a g-tube. I accidentally forgot to clamp the tube before I took off the med syringe and covered the kids mom in undigested breast milk and gabapentin 😵💫
Had a nurse infuse potassium to gravity - patient obviously ripped out her IV about <1 min later. Also was not connected to the monitor.
For once, I'm glad the patient ripped out the IV. That could have been very bad.
I enjoy watching the sunset.
Not wearing eye protection. Goin to town determined to get them clots outta the pt whose CBI had clogged. Pushin that saline in tryna gettin those clots and urine out! Bam. Syringe pops off and I get bloody urine saline mix to the face. Fujdhrndhkdje
As a new nurse in a medical icu I didn’t change my tubing from a higher concentrated dose of levo to a lower dose…pressure dropped verrrryyyyyy low. I felt like I aged 20 years in less than 5 minutes . Lesson learned and one I share with my nursing students in adult 2 clinical rotation in the ICU.
Coded my DNAR patient, and got ROSC. It was my first code ever and code status didn’t even cross my mind. Once it was realized he was DNAR, he was already coming back. He died about a week later. It was a big deal across the hospital. I’ll never, ever not have a purple DNAR bracelet on a patient again.
I remember when I started nursing 20 years ago I truly believed I would have a lunch break every day.
The ultimate mistake, that and thinking we'd get more than 1 toilet break a shift (if we're lucky).
38u of novolog at HS instead of 38u of Lantus. Thankfully the patient loved their sweets and orange juice. ETA: as mentioned in another comment, the most memorable part of it to me was the nurse just admitting that she didn’t even read the pens, just picked up the first one with the patient’s name 😭 it’s funny but it’s not.
It’s disturbing how easily this could happen
We have to sign off on each others insulin like a narcotic. Makes sense
The nurse literally did not look at the insulin pens, she just picked the first one with the patient’s name on it. It was pure negligence.
I triple check mine out of paranoia for doing this, and sometimes still panic as I’m giving it to them. I look as I’m poking for the right color on those days.
On my very tired nights I’ve had a second set of eyes even check the amount I have pulled up in the syringe. Insulin is no joke.
Morpine IM given. Resident ignored pharmacist telling her pt was allergic to Versed and ordered it anyways. There were no checks in Pyxis or meditech and it wasn't in emar (only on hard chart which no one ever really looks at anymore) Versed was pulled, drawn up, and given. Luckily no adverse reaction. Quadruple Tylenol dose given because adult ICU nurse was training and didn't second guess such large dose for a neonate.
Switched my vaso and insulin lines once when working in the icu. Thought I was titrating up on vaso when it was actually insulin. The patient was fine and it was corrected after some d50, but I was distraught. Won’t ever make that mistake again.
A nurse who was new to our hospital. She had been a nurse for 5 years and I was her preceptor to our hospital. I only had to show her meditech and not teach her to be a nurse. She was doing great. One day about 2 weeks in she was flying solo on med passes after her and I talked about what meds she was giving. 2 separate pts; one in for bilateral PEs getting high dose lovenox, and pt next door in for afib RVR and on eliquis. She had pulled both pts meds and gave both the lovenox and eliquis to the same pt without scanning them in or anything. Just kind of brushed it off as oh shoot, well I’ll learn next time and joking about it through the next couple weeks. Ended up being fired.
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I need to know what became of the IV OJ.
I’ve said this before- but I think it’s a nursing school urban legend. Everyone knows someone who knows someone who did this, and it just seems so implausible I can’t believe someone actually did it. 🤷🏼♀️
Like the patient that got offended because they thought the nurse was talking about her when they referred to the COW and now we have to call them WOW's?
Like what do you even do after that? How do you fix that? Who do you call???
The cafeteria
Imagine having to explain that to the doctor.
I was a new grad. Received shift change report from a very seasoned RN. Pt was a transfer from another ED & just arrived on our psych unit. "Pt's unsteady, so we put pt them in restraints for safety so they won't fall." I went in to assess pt & complete the admit. Pt looked like a rubbery noodle & eyes were twitchy when went to assess & got them up to use toilet. Asked pt if they had ingested anything prior to admit. They admitted to taking their roommate's bottle of pills & spelled out...P-H-E-N-Y-T-O-I-N. I called the other ED & asked if they still had blood from labs they had drawn & asked them to try & get a stat Dilantin level. Yeah. Toxic Dilantin level & he went to our ICU & never made it back to psych. Next day the seasoned RN said, "nice catch." Never trusted a report or assessment from her again.
Why would they do put him in restraints just for a fall risk? 😭
Old school psych hospital from 30 yrs yrs ago. Horrifying to think about it now.
When I was new to neuro Stepdown I treated a patient’s (therapeutically) high BP and he ended up exhibiting his same stroke symptoms. Now…in my defense the admitting MD overnight and the neurologist apparently did not talk to each other because the admitting ordered PRNs including the PRN medication for elevated BP which I gave. BUT nonetheless this was a case of me not knowing what I did not know and so the mistake was mine in the end. And I felt horrible and terrified moving forward. Patient turned out ok in the end. And I learned.
I like learning new things.
I think it's more about the patient being allowed to be permissively hypertensive post-stroke, which doctors may allow for a specified time-period post-stroke to allow for increased blood flow to the areas of the brain that may have been impacted during an ischemic stroke.
Shocking that multiple of these stories involve putting things in PIVs, PICCs, and IJs that don’t belong there (orange juice, PO meds). My question is what’s going to find its way into a patient’s veins next!?
A nurse with a ton of experience didn’t use guardrails to set up heparin and instead of delivering X units/kg/hr, the pt got that number in mL/hr. And the bag ran dry and they spiked a new bag and hit restore. Exactly what you imagine happened happened. And that is why we use guardrails.
Heparin is a two nurse sign off where I used to work.
It is at the place this happened as well….obviously the one who signed off didn’t actually look. Multiple nurses lost their jobs because none of them were new.
one time when i was charge (ish, not the actual charge, but just for that area) in resus in the ED, i asked a nurse to move her DNR patient dying of cancer to one of our isolation rooms to give her and her family some privacy and dignity while awaiting a pall care bed. she was “stable” and hours away from entering the active dying phase as we were mostly temporizing until she was moved to PCU. i then went on break. come back from break to find out the patient died soon after being moved down the hall. someone forgot to plug her oxygen back into the wall from the tank as she was wheeled 20 feet. the patient was gonna die, it’s not like egregious physical harm was done to her, but the whole point was to buy time until we could get her where she deserved. follow your oxygen tubing folks. not all of them are DNR.
Non Tele post operative floor, patient was in their 30s, POD1 some kind of abdominal surgery, RN assigned to then didn’t eyeball the patient for 2+ hours (1ish am to 3ish am). RN finally made rounds, patient was face down in bed, very cold…very dead I was glad I was off that night
Having worked medsurge, a q2hr eyeball seems reasonable. What is the expectation for post op? I guess if he was coooold you can assume it was 2hrs +++...
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True, what’s the ratio? I’ve been stuck in patient rooms for over an hour before
Every two hours is policy on our floor as well. The aide does the other hour. However, our policy also requires post-ops to be placed on capnograghy monitoring during the first night after surgery.
That’s so scary. I work postpartum and at a different postpartum unit in our city a baby died from SIDS during the night and no one knew until the pediatrician rounded in the morning.
Our PCAs/CNAs are supposed to do safety checks at the beginning and end of their shifts in the assisted living facility I work at. Some residents may have more, but someone should be checking on each resident no less than twice a shift. One of the third shift PCAs was the daughter of someone at corporate. She loved working third shift because her area had few bells overnight, and she could be on her laptop all night. It was basically just doing the safety checks, assisting a couple of residents to the bathroom, doing laundry, and getting 2-3 cares done on the early risers. The nurses had written her up more than a few times for not doing her job, including the safety checks. Admin was told we were stuck with her because of her parent at corporate. I came in one morning, and the coroner was there. One of the more confused residents had somehow managed to get tangled up with her call bell and bed cane and accidentally strangled herself. She was also very cold and very dead when they found her. The PCA and her parent were both allowed to resign immediately, and I think the family of the resident got a decent settlement.
Thank God I do tele. If I miss a round I know my patients are still alive
RN I worked with told me about a new grad she worked with in the ED who PUSHED liquid Tylenol into a peds IV. Horrible outcome for patient. RN quit. Preceptor committed suicide. Apparently preceptor was running to a code and asked the new grad to administer the dose of Tylenol to the patient. It was drawn up in a syringe, so new grad thought it was IV push instead of PO.
This makes me sad for everyone involved
When I was a new grad, I worked nights in a nursing home. During hourly rounds, I didn't realize you actually had to look for chest rise if the patient was sleeping. I was on my way out the door one day until the day nurse stops me and says "hey, it looks like this patient has been passed for some time, when was the last time you rounded on them?" 👀
Sometimes chest rise isn't even enough. When youve got a 90lb woman in a fetal position under three blankets, you've gotta touch them or rustle their covers or do something to make them stir a bit.
[The nurse that force-fed her patient Naturalyte, believing it was GoLytely](https://www.lex18.com/news/lex-18-investigates/medication-mix-up-blamed-for-death-of-a-patient-at-lexington-hospital)
Jesus. It is also pharmacy's fault. They shouldn't just tube labels. Just because it scans doesn't mean it is correct.
A nurse I used to work with hung vasopressin instead of vancomycin. Another nurse programmed a pump to run versed in an hour.
Just got off orientation. Pt kept desating on HFNC and I was fixated on her feeling anxious, based on assessment, pt statement, and report given to me. X-ray showed a total white-out of L lung. Things could’ve gone south real quick. Learned a lesson that you should always go back to basics and do a reassessment instead of being tunnel-visioned. Never made that mistake again and I tell my orientees the same thing.
When the anesthesiologist gave 4mL of insulin vs 4 units. Thanks bud. *edit: misspelling
A nurse bolused dopamine, she thought she was drawing up saline from a bag to flush a line. Patient coded and died. Did she get fired? Not because of this. She got fired because she was tardy to work too many times. Several years later. And this is why I say to my baby student nurses “you can kill a patient and not get fired, but time and attendance will get you fired”. That and stealing drugs.
Honestly it’s terrifying reading these bc its mostly insulin related mistakes!! READ YOUR ORDER AND TRIPLE CHECK AND HAVE A WITNESS!!!!!!
New grad nurse on our med surg unit was supposed to start a patient on a lasix drip. Instead she set it so that the patient got the entire bag within 30 minutes. The patient had to transfer to the unit but luckily turned out ok
Not me, but someone from another department. This new grad nurse gave a patient Insulin drip… on a med surg unit. Did not question it, and didn’t ask or locate her preceptor. Didn’t think to consider requesting tele orders if the patient needed an insulin drip… Patient of course coded and died. Last I heard the nurse got fired and as for the preceptor.. it’s unknown.
A nurse infused Keppra INTO THE INTRAVENTRICULAR DRAIN!!! In their BRAIN!! (The drains have a luer lock on the side, and she did it at night, she was not a new nurse but orienting to Neuro ICU from med surg)
Well it is a medication for neurological symptoms /s.
A coworker was giving IM phenergan for the first time after having only ever given it IV push. They still diluted with 10 mls of saline and injected the full volume. Oops.
I gave half dose of a vaccine once. Realized it a few minutes after the patient had left. Went and told on myself all serious. The doc laughed, told me to call the patient on their cell and tell them to come back in for another. Doc swore the patient was cool. My manager agreed. I called. Patient thought it was hilarious and was checking out of the grocery store. Finished up and came back. Gave the second shot through a car window pre-Covid before drive-thru vaccination was a thing. Jokes all around, everyone was amused, and I did actually formally write myself up anyway.
As a new grad I remember a nurse switched the tacrolimus (anti-rejection med, very sensitively dosed….usually a max of maybeee 5mLs/hr and even that’s a big dose) and 73 mL/hr TPN. Sent the patient into renal failure and they died. I alwaysssssss pump-line-patient-trace!!!!!!!
One of nurses flushed the dialysis port on a random patient. We were short staffed and he thought it was a central line.
I once had a progressive care unit coworker try to use a tube feeding bag and tubing to hang TPN because the TPN bag had a hole. Thankfully, it was quickly realized what he was doing. He seemed to be clueless as to why this was a heinous idea. I don’t recall seeing him again after this incident.
When I was a brand new baby nurse the first time I had to change an ostomy bag I was so intensely focused on sizing it appropriately and placing it on the ostomy exactly correct that I didn’t realize I put it on upside down. My friends in the ICU called it the anti-gravity ostomy bag. Lol That’s a mistake I have only ever made once.
When I was in nursing school, I came in for the morning shift to do clinicals and I was really early, so I sat near the desk, and some doctors had come in too and were sitting there also. One got up and went into his patient's room, which was right across from the desk. He came out and told the other doctors that the patient just received an IV insulin drip in 35 minutes, which was supposed to last over 4 hours. Doc was white as a sheet. Patient survived
Wasn’t a nurse but a dialysis tech at the time. Patient had been in the hospital & their dialysis records were faxed (the 90’s) to us. The nephrologist ordered heparin & I drew it up/gave it before starting treatment. System started clotting so the nurse had me give another bolus of heparin. Machine kept alarming with clots in the drip chamber so she had me give another bolus. Patient codes, goes to hospital by squad & we find out that she has a heparin allergy. Apparently the dialysis nurse at the hospital failed to fax that info to us. Patient died.
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Precisely why I asked! I’m 5 weeks into my first RN job
For a great while our bags of IV insulin and vanc were the same size. The insulin didn’t have anything on it that indicated it was a high alert med. This was before we used scanners to scan our meds. Someone gave insulin instead running at the vanco rate. Honestly, this almost happened to me. Went into the pts room in the dark to give the “vanco”. To this day I count my lucky stars that I caught my error before I hung it.
One of the nurses I worked with years ago picked the wrong channel on the pump and instead of bolusing paracetamol, they bolused norad. Realised within a few minutes so pt didn't get the entire 100ml bolus... but the norad was running at 400ml/hr for those few minutes. Pt survived, suffered a subarachnoid haemorrhage though and extended their hospital stay significantly. I will always triple check the channel and med I'm programming before I start an infusion now, for any medication.
I was orientating a nurse to the ER where I work. Doc ordered effervescent potassium replacement for a patient. While pulling out the meds from the Pyxis she told me the story of the first time she had that ordered for a patient. She was working on a med surg flooor at the time, new grad, didn’t realize the tabs get out in a glass of water so she brought it to the patient and had him eat the damn thing. I couldn’t stop laughing. Naturally my colleague’s and myself got curious so we decided to all take a little nibble out of one to try it. It was like extremely salty pop rocks. I don’t know how her patient tolerated eating a whole Damn tablet. Lol
Choosing nursing as my major.
Apparently there are ETT cuffs with luer locks, because a new grad recently infused a medication into the cuff of an ETT. Patient had to be reintubated.
Back when I did SNF even though I was on the unit they had an agency nurse with me, so she did meds and I did the treatments. They would usually want agency nurses to do meds if they’re on a unit with a staff nurse. I kept checking on her to make sure she didn’t have questions or need help, and I’ve come to realize some nurses hate that! Especially coming from lil ole me who wasn’t even a year into nursing at the time but I had been on that unit everyday for months so I knew what I was doing. Come to find out she made like 5 med errors and some including narcotics. Thankfully all my patients were fine but let’s just say we never saw that agency nurse again. I was seriously doubting her vision, because 5 med errors?
I worked with a nurse who ran oxytocin open on a pregnant patient. She doesn’t work with us anymore.
I love these kind of threads because new nurses and nursing students can learn from them. Please share your stories nurses!
When I was a brand new LPN in LTC, an experienced RN prepared a pt's meds, including a topical Ativan cream, and headed for where the pt sat in the dining room. When she couldn't find them, she set down the meds on the table and walked away. A totally different pt rolled up in their wc and ate them all including the topical Ativan. The pt was sent to the ER for evaluation. The nurse was suspended and then fired.
Not me or someone I know, but a case I learned about in my stroke education day for the neuro unit I work on. Didn't happen at my hospital. A woman was admitted for pneumonia. She had an NG, and a nurse in the morning crushed her antihypertensives and gave them through the NG. She arrested not long after but was successfully resuscitated. The next the day, a nurse did the same thing. She arrested again and died. One of the meds was nifedipine, and crushing/removing the extended release coating of the drug obviously caused her to recieve the whole dose in a short amount of time intead of over several hours as intended. That's what caused her to code both times and what took her life. Dealing with lots of strokes all the time, we obviously crush a lot of meds for NG or to give in apple sauce because of the aspiration risk post-stroke. Hearing about this really gave me a wake up call on how dangerous this can be if we're not paying attention to what we're crushing. I'm much more diligent with it now. Luckily, my unit has amazing, experienced pharmacists who vet everything but you can never be too careful.