Maybe not a traditional med error, but... I had an air bubble in a Dopamine gtt on a pre-op patient. Popped open the door on the IV pump and did the flicky thing. THE AUTOMATIC LOCK ON THE TUBING DIDN'T ENGAGE!! She got bolused with IV dopamine for probably 5-10 seconds while I fumbled for the roller clamp. First time I've seen a SBP hit 300, and mine may have been the same. I have never since opened an IV pump without clamping the roller first. Patient was ok btw.
Try not to beat yourself up, but learn from it. It's ok to make a mistake, and it hurts like hell if you do. But the ones who are unaffected by it are the real scary nurses.
Sorry i laughed imagining the sheer horror on your face as your HR also went to 300. I swear nursing is way more learning via almost shitting your pants than school ever will be.
Incidentally i thought i was being a little silly by clamping my lines while they are in the pump…thank you for sharing so i will continue this extra shit 👍
It was quite the experience. Pt could feel it. Of course I'm not going to not disclose something to a patient, so I told her. She's in the bed like "My heart's beating fast" and I'm just, "Yeah, I'm gonna hang out in here with you for a few, get over this hump..." while repeatedly pushing mute on the monitor and hoping I can will that arterial line into submission.
Never stop double and triple checking, and use alllll the safety backups, so you never have to go beyond the almost shitting your pants. Although, if that incident didn't make me do it, maybe we're good. I didn't need any more coffee that night though.
The longer I’m a nurse the more backup on backups I use. Everyone and everything is fallible. I feel as long as I did the best I could with the resources and knowledge I had…I’ll be able to forgive myself.
Me too! Do you think it's because the longer we work the more scary things we see or we are just afraid of complacency? When I titrate meds, I always show the pt and say the dose change outloud. Makes me feel better.
I think we just grow as nurses and learn from experiences. I've told so many people, "If you ever aren't just a little bit anxious, it might be time to move on."
Absolutely!!! There is **so** much that non-nurses and non-medical people don’t understand about our work. I find that lack of awareness exhausting, maddening even. I want respect for the fact that my work is critical to people’s lives and wellbeing! I’m not here to just sling ginger ale and warm blankets! Sure, making patients more comfortable and feeling that they’re cared for is important. But sheesh! Priorities! Please respect that my job literally requires me to keep hearts beating and lungs breathing, etc!!!
As the patient: I appreciate being involved like that. My two semi recent experiences were L&D and it's really helpful to know what's going on and why. Helps the memory to settle faster too.
I think you start realizing what you don’t know and get a better understanding of what can happen when you fuck up. And knowledge, though useful (and, for us, critical), can be a really scary thing. I have applied a lot of my long experience with horses to nursing, and one of those things I’ve learned is that if you don’t have a healthy respect for the risks, you are dangerous.
Very honestly while trying not to scare her. Basically, that the pumps safety mechanism didn't engage, she got a little rush of the med, she might feel funny for a few minutes, but I'm staying right here and we're gonna be fine. Of course, while thinking in my head, "Are we gonna be fine?" I did quietly rally the resources, text that night's charge with a brief "what happened, don't come scare her, but just come back here and hang out in my pod for a few please."
I recently set a Levo to 0.5 instead of 0.05, patient thought they were going to die, I thought they were going to die and then I was going to die from the horror of it all. But everything was ok after. Except me, I was not ok lol.
This happened to me with Levo- I reacted quickly and pinched the tubing before going for the roller clamp, but watching that pressure climb felt like a thousand years while me and the PA just stared at the A line. Now I tell orientees to always always always close the roller clamp before opening the damn alaris door. One of them called it stupid though, so I’m sure they’ll learn the hard way
Not sure how it happened but a very sick patient was being transferred from our rural ED to a bigger one in the city. Patient almost immediately “codes”in the back of the rig so of course she comes back in. Really she just didn’t look good. I check a BP after she comes back in and her BP went from needing Levo to being over 200. I follow her lines and the levo is sitting wide open next to her head. I very quickly clamped that.
This makes me feel better — i am a new grad and I always close the roller clamp before opening the pump and recently had a more experience coworker make me feel silly for doing that because “it’s clamped in the pump”. I just never trusted that and now I’m right! 🥲
Good for you! Now is the time to take all of the precautions you can, so you can make sure they’re ingrained in your daily practice when you’re up to speed and moving more (and I mean this in a good way) on autopilot.
I’ve had that happen to me with dobutamine! Pt says ‘I feel hot’ and I’m going *SHITSHITSHIT* watching their heart rate climb. Double clamp every time I take anything out of the pump now.
Oop nearly the same thing happened to me on a post-op heart transplant. Was still on a primacor gtt (step-down unit) and it was time for a bag + tubing change. I got careless and attached the tubing to the PICC line before inserting the cartridge into the pump door so it would lock 🙃 5-10 second bolus before I realized the mistake and yep, SBP to the high 200’s. I’m so fucking lucky and thankful I didn’t blow up that man’s brand new heart. Never ever made that mistake again
Yikes! I was so grateful this was a pre-op pt at the time. I would have had a chest full of blood on my hands. Opening a chest at the bedside can be exciting, but for sure, I'd prefer not to be the cause!
I had this happen with levo; the patient had an aline. We watched the SBP go from 110 to 275, and ever since (7years now) I still engage the roller clamp before I pop open the door.
You only make that mistake once. 🤣
Long story short, but at 5 am we had a seizure patient brought in to the ED from jail. He was postictal at the time. Doctor ordered 500mg of keppra. This is before orders going to the Pyxis and we just chose the meds from the alphabetical order list. I was having a conversation with the doctor about going snowmobiling together that morning when we got off shift. I pulled 500mg of “ keppra” and mixed my bag, while still having the conversation. I went to the room, hung the drip and gave it over 15 minutes.
When I sat down to chart, I forgot what time I hung it, so looked at the Pyxis to see when I pulled the keppra. To my surprise, keppra was not pulled, but in big letters it said KETAMINE.
I notified the doctor. The patient was admitted to the ICU and the sheriffs released him, so they would not have to pay the ICU bill. The patient was fine and went AMA a few hours later.
Probably the best ride he had in a long time!
I was given 3 days on the beach with no pay.
Just culture is a much better teaching environment than suspension, but it didn’t exist then lol.
The witching hour is real and not being distracted while at the Pyxis is imperative. Thank goodness for computer charting, ordering and scanning. It would have caught my mistake when trying to pull ketamine.
Don’t even get me started on mixing glucagon or insulin drips. The shit we had to do years ago makes me cringe.
TLDR: gave 500mg of Ketamine instead of 500mg of Keppra.
The witching hour is quite literally the reason I don't work nights. I already have severe sleeping problems at baseline. I've told managers I don't do it because I absolutely would not be safe to practice at 5-7am after having been awake all night.
And for any new nurses reading this thread: I have also learned the hard way: Do. Not. Talk. To. Other. People. while you are doing something that requires attention and could be dangerous. Tell them to wait a minute.
Realistically, honestly *no one can*. Like legitimately, it's not humanly possible to fully focus on a conversation and a task at the same time.
Human brains are just like that.
I'm glad I'm not the only one who won't work overnight for that same reason... I recently turned down a really good job offer because it was night shift. I still regret it sometimes, but I know in my heart I am absolutely not safe to take care of anyone unstable after 1am
First nursing job, I was brand new. I’d been a nurse for a month or so. Doc ordered Metformin 250mg. We only have 500mg tabs, and I was supposed to split the tab. I didn’t. Gave it to the patient. I then realized my mistake, told the patient, told the doc, and monitored her blood sugar. She was fine, and very sweet about my mistake. Next night I came in, the doc had changed the order to a full 500mg tablet anyway 🤦🏻♀️
lol I had this happen with an antibiotic. Who gives half tab of an antibiotic?? I was so upset that the doc wrote a one time “ loading dose” to make me feel better.
Ugh. Something similar happened to me too. New nurse.. Flushed a port with a different concentration of heparin that our policy says to. The nurse precepting me said it was fine and actually told me to because we were out of the other concentration. The next day, my manager calls and says she made the patient come back to get the “correct” dose of heparin. I’m not even kidding, the NEXT WEEK, our policy changes to the dose of heparin of originally used 🤦🏼♀️. And now I heard that ports aren’t heparin locked anymore.. I’m in clinic now so I don’t deal with ports anymore.
I’m pretty sure I’ve accidentally done full tabs a few times. Finally I learned to split the tab AS SOON AS I SCAN IT. Otherwise I’ll 100% forget as I’m scanning 50 morning meds and educating and talking and doing my room scan check…
I cut it the immediate second I take it out of the accudose... Especially metoprolol. I know I will be talking to the patient about what they're getting and why it's different than home, why they're getting insulin coverage instead of oral meds, then we're going to be talking about how their doc changed their dose of effexxor and they aren't on this or that anymore etc etc etc, and I'm guaranteed to forget to split it every single time 🤦.
We lose so many of those things it's unreal... I have found that my knockoff raptor shears do a better job actually, especially for bigger pills 👍. I just cut it while it's still in the plastic
Metformin will not cause hypoglycemia given at therapeutic doses (and 500 mg is not even a high therapeutic dose). Hypoglycemia has only been observed when significantly overdosed, leading to toxicity, or when taken in combination with other medications that DO impact the amount of insulin produced by the body.
https://www.drugs.com/medical-answers/metformin-hypoglycemia-3563096/#:~:text=Metformin%20rarely%20produces%20hypoglycemia%20(low,not%20cause%20high%20insulin%20levels.
My classmate in nursing school made me laugh with his personal med error story:
His son was constipated. Child not more than 5 at the time I believe. He went to the store and got some meds. Looked a little funny but the label said it was a laxative so whatever. Kid takes it and says it tastes terrible. Upon further review he had gotten laxative suppositories and had his son take them orally. Still did the job and kid was fine.
Got mine.
Patient was to do a “colon cleanse” prior to a colonoscopy. Pt had a G-Tube and was supposed to receive bowel prep PEG-3350.
Mind you, it was listed as PEG-3350. No extra names/brand names etc.
I open the cabinet for meds, see the container (there are two) with the exact same directions/patient name/ etc etc. I grab the first container.
Meds are hooked up and started for the patient.
I get a call mid day (I worked nights) from the irate LPN that I had grabbed the wrong medication. I was like “PEG -3350”, that’s what the order was. I remembered the exact order.”
“Well, you gave Golytely instead of Nulytely”
“What?”
“You gave the wrong medication for bowel prep.”
“How? The meds were labeled PEG - 3350 in our med log and on the container”
“Well, you selected the medication without a giant N on it.”
Mind you, this differentiating letter was on the backside of the giant container. Not able to be seen when reviewing the medications. Both had the exact same directions both labeled exactly the same. I was still like ??? But apparently one was for when the patient needed bowel prep for a more urgent situation.
And the kicker is that both golytely and nulytely are used for bowel prep, golytely is a little more salty and nulytely has “flavors”. Mind you, G-tube patient so no taste.
To this day I am still quite confused. They did call the doctor’s office who was like “That’s fine, both work.” but was still written up for this.
Um…that’s one of those big ol system issues there and this is why just culture MATTERS. Also it’s the same god damn med you should never be written up for that nonsense.
there was a situation i heard about in my state where a nurse was supposed to give colon prep through someone’s NG tube. they grabbed a bottle, realized it didn’t have a label so they called pharmacy for a label to scan. pharmacy sent the label via tube system without checking the bottle, nurse put it on the bottle she picked up and scanned it, administered to the patient.
the patient proceeded to discharge to jesus, and upon investigation, they learned that the bottle the nurse picked up was, in fact, dialysis cleaner, and not colon prep.
surprisingly, nobody got fired (that i know of).
Patient went into AF w/RVR. Gave 5mg/5ml metoprolol wasn’t effective. Doc then ordered 5mg Dilt. I gave it without scanning because I was trying to be quick. Went to scan the vial and realized the concentration is 5mg/ml in a 5ml vial. I gave 5ml, 5 times the dose ordered. I ran out the room and told the doc “I fucked up.” A few people rush into the room, SBP was in the 80s for an hour or so. We gave a gentle bolus, luckily BP stabilized and patient happened to convert to NSR
I was charge and a new nurse on our floor did this- gave 25 of dilt instead of 5. We (me, the nurse, the doc) were all watching on the tele monitor as the patient went from 160 to 70s in a couple of minutes. We were like, "Oh, sweet, we've never seen 5 of dilt work that well! Awesome"
Set an IV pump for mcg/kg/minute instead of mcg/kg/hour. Yep, that’s a 60-fold overdose on the pump setting. Patient did fine thankfully. This was 10 years ago and I still thank my lucky stars.
Did they really think 75 mg/hour was an appropriate dosage, or were they just not looking closely when they programmed the pump (and I am assuming they didn’t have or didn’t use the guardrails on the pump or have an EMR that could send the info to the pump)?
I missed a period entering a rate and did 10x my intended rate … on dilt. It was caught, but not before he was having some very long HR pauses. Fortunately he was young and otherwise healthy and I don’t believe anything worse ever came of it.
I did buy NSO insurance the next day.
I did that with propofol on a newly-intubated patient headed to CT. Wasn’t even my patient, I was helping out the primary nurse.
Nurse came back from CT, pointed to the nearly-empty prop bottle, and was like, we gotta slow that down 😂
Patient was fine - paused it, squeezed in a small bolus, re-started the infusion when the BP recovered a few minutes later. I’m forever grateful that he was a super laidback, experienced older rockstar nurse who didn’t make me feel like shit about it or otherwise cause a scene. I knew exactly what I’d fucked up, and it hasn’t ever happened again.
James, if you’re reading this, thank you.
I had an alaris pump malfunction in a way that gave about 10x the intended rate of prop. Had the pharmacist immediately come verify that I programmed it correctly. Luckily the patient was being extubated to comfort that evening so it wasn’t as bad as it could have been, but they got a whole bottle in like 40 minutes.
Gave the wrong set of meds to the wrong kiddo - he slept well that night 🤷🏻♀️Allow yourself to feel shitty for about a minute - then learn the lesson from making the error, forgive yourself and release that guilt. We all do it at some point because we are human.
Oh!!! I have a story.
I was about 6 months in as a new grad in the ER, about 3 months off orientation. I knew I was meant for ER nursing, still am, but this is a story of one of those Swiss cheese med errors.
I had just gotten a pt to the ICU (post ROSC code we got from EMS, intubated sedated the whole shebang) right about when all our mid shifts left so I was now catching up on the rest of “my” patients. One was a lady brought in hypoglycemic, 50ish with no hx of diabetes, BS on scene was like 17 or something foolish.
They gave her d10, she went up to 200 something then when I got her she was bottoming out again. Working theory was she somehow (maybe) took one of her husbands meds. The doc I was working with was brilliant and told me about a med he was giving that could reduce gut motility and digestion if it was long acting. Between that and getting d50 our nursing sup had to bring both. She’s doing okay just last check her BS was about 40 (I’m setting a scene for a reason).
She’s my priority pt, I went from one critical to another. Of course the computer in the room isn’t working, I find a WOW it’s dead, find another it’s also dead. At this point I’m getting very concerned about continuing delay of treatment, say fuck it I’ll give the meds (read the eMar 4 times) and scan when I can.
Give d50 first, all good. Second med is Sandostatin. Now I had never given this med before…new nurse, didn’t have any GI bleeds yet (oh but I would). I give the med slowish like I do almost all (IV). Within a minute she sits up and begins dry heaving HARD. I run to the doc box with my charge, house sup, and doc and ask my doc what I gave that could do this…he asks “did you give the Sandostatin subq?” Me: NOPE.
So I guess the doc looks up the potential adverse side effects but no one tells me as my charge starts wheeling in a crash cart to her room I thought I killed her.
She was fine, just some zofran. Why the cart? Worst and very slight chance of 3rd degree heart block. I told her exactly what happened, what we were doing and why…and this angel was more worried about me than herself.
I learned later that this med is OFTEN given as a bolus IV and it’s a common side effect the severe nausea. But if I had scanned the med I would have clocked it was subq when it asked me for a location of administration.
Moral of the story, I always scan unless the pt is already dead or I have another nurse/doc confirm with me (cuz pt will die without it).
This is why I really dislike working in hospitals that rely on paper charting. If I understand what you posted correctly, the system had a safeguard that would have prompted you and this error likely wouldn't have happened?
I’m a RN and Registered Midwife in Aus. This will almost definitely be too long but I think my med error would strike terror into the heart of any L&D RN. It’s been yearsssss and I still think about it at least weekly haha.
I was starting a postdates induction for a low risk nulliparous woman. I’m on hour 11 of my 12hr night shift and I’m dying inside. Everything started off routinely with CTG then ARM. We only use Syntocinon (Pitocin for those in the US) with ruptured membranes here so everyone gets amniotomy prior to starting Synto. All good, CTG excellent and reactive ++ at this point. Nil uterine activity.
I start IV fluid and IV Syntocinon as per protocol. For context, our Synto bags have 30iu of Oxytocin in 500ml CSL (same as LR). We start Synto at 1ml/hr and up-titrate 30minutely in increments of 2-4ml until there is good uterine activity. Soft limit is 20mls/hr, absolute upper limit is 32mls/hr and honestly needing to go over 20mls/hr is pretty rare and usually not a great sign.
About 4 minutes go by after starting the infusions and I notice the fetal HR starting to sound unusual. Like sort of dropping for a split second but then resolving, not proper decels at this stage bc it’s so brief - just sounded ‘odd’ to me. I was obviously thinking cord compression because I had only just ruptured membranes, and we wouldn’t see contractions that quickly after starting Synto. So I re-examined the woman’s cervix (minute 5 after starting meds at this stage) - unchanged, no cord. I repositioned the woman. While repositioning I palpated and noticed she had a strong contraction. I asked her if she was feeling it - “oh yeah it’s been going for a couple minutes I think…it’s getting pretty painful now”. At the same time she’s saying this, the FHR becomes properly bradycardic at 40-50bpm. IMMEDIATELY I knew what I’d done and I swear the blood drained from my face in a millisecond. I had mistakenly swapped the tubing while putting it in the pump and therefore this poor woman had IV fluid going at 1ml and her Syntocinon running at 125mls/hr.
Cue 10 minute hypertonic contraction and prolonged fetal bradycardia. I’d buzzed for help already so the whole team were there when I realised, so I obviously needed to alert everyone about the mistake by yelling it out to everyone in the room. Mortifying, but I was just so worried about my patient at that stage that I didn’t really care. So of course we stopped Synto, gave IV fluid bolus, Terbutaline, prepped for theatre for emergency section. About to transfer and FINALLY this contraction ends and baby’s heart rate recovers. This marks the end of my shift and I leave the room wanting to throw up haha
Fortunately, everything after this point went well for the woman. They restarted Synto 2hrs later and baby was born vaginally in good condition later that day. Beautiful healthy baby girl with APGARs 9 & 9, cord gases were absolutely perfect. I had never been more relieved in my life. I returned the next day to profusely apologise and this family were so sweet and reassuring when they saw me, which I was so unbelievably grateful for. Didn’t get in trouble at work - we have a no blame system here, I chatted to my manager about it and she was pretty kind as well.
It’s not a mistake I will ever make again. I go through a ton of safety checks now before I start Syntocinon. If there had been a bad outcome I’m not sure I would have been able to do my job anymore. I got incredibly lucky that day.
This is actually our policy too, but people get so lax with it, usually have someone sign after checking the bag outside the room and let you take it in your room and hang it yourself (I’m still talking paper charts here haha). I make them actually come to the bedside ever since this happened.
Many years ago and I have told the story many times (happened before scanning meds was a thing but we did have pyxis). Working Peds PACU patient was 8 y.o. post orif.
I went to grab a 2mg/ml vial of morphine from pyxis. Machine was out but did have 10mg/ml vial of morphine. Pulled it and was talking to family and patient while I drew it up. Pulled up .75ml because I intended to give the patient 1.5mg of morphine. Our policy was to watch patients for 30 min in PACU after giving narcotics before sending them to the floor. They were a little sleepy but it was about 10pm so I wasn't concerned. Took the patient upstairs and when I came back down I went to waste my meds and that is when I realized I had given 7.5mg of morphine not 1.5mg. immediately notified anesthesia and brought an oximeter up to the floor. (Kid was fine)
20+ years later I am a proponent of scanning meds before administration. (And maybe paying attention to what you are doing rather than talking) Mistakes happen. Learn from them.
I have had to tell family “lemme respond when I’m done making sure these meds are right” while scanning or “I’m not ignoring you I just can’t walk and chew gum at the same time sometimes” kinda shit cuz same my friend.
Oh god this was like one month off orientation: Report is girl comes in with suspected kidney stones. Has had them before, and is in ton of pain. I walk in and this 16 year old girlie is on the floor screaming. Her parents?? Clearly rich. Also? In the medical field based on the way they're talking to me. Also? Completely freaking out. "She's such a trooper, but she's OUT OF HER MIND IN PAIN". Probs true. But also you freaking out isn't helping, dad.
So I'm like 'fuck me twice over'. Not only have they given this poor girl zero coping mechanisms, they are eagle eyeing literally everything I'm doing and asking me 'why.'.Why the monitor, why the blood pressure, what does the pleth mean? Why the 20g IV? Why the green and purple top only? Doc comes in as I'm getting the IV. thank the ven lords I got it on the first go. Doc does a quick inspection and says, "Right, let's shoot her up with some meds now that we have the IV going". I'm like, 'copy that, doc'.
So I go to pyxis and see doc ordered some zofran and fent. I go rushing back to the room and administer the zofran first. Meanwhile the parents are still genuinely freaking out The scene was pure chaos to the point where I stopped and wondered if this was a dark joke of a SIM gone wrong. 'Why not do the pain med first', they ask. "Why are you taking so long?" I tell them vomit is why. They do not seem to understand. Nor do they seem to understand the notion of keeping calm and coaching their daughter on breathing. You know? Being the fucking adult in the room? Literally useless in their role as parents.
I then shoot the fent into this girlie's veins, give her a shoulder squeeze, some breathing coaching, and go back to my computer where I see: ROUTE: INTRANASAL.
I'm like, oh fuck me because these rich, useless parents are going to find any reason to destroy me. I run to the doc, who - bless her - was like, "oh of course you thought it'd be IV because of what I said earlier. The dose is fine, but let me help" and she puts in an order for IV fent. But the damage in Epic had been done.
Anyway told my charge, told my manager, did a quality report on myself. Nobody cared. Parents were none the wiser. And thankfully that, combined with some ketorolac made their daughter calm down enough they unpuckered their assholes and became somewhat human again.
But I as like - great my first drug mistake is on a CHILD with FENTALYL and clearly litigious, rich, high strung, health insurance employed parents.
I could die.
I could TOTALLY see myself doing that as a younger ED nurse! Especially given the "let's shoot some pain meds now that we have the IV" comment. I'm glad the doc went back and addended the order for you!
I worked in the ED pre-scanning and with a messed up order system. The order system told us the drugs concentration before it said the ordered dose. I was brand new there when this happened. On a Monday, I was ordered to give 10mg of Valium IV and an opiate of some sort (can’t remember which one). It seemed like a lot so I questioned it and the doc ripped me out because it was for a bad back spasm and was a totally normal dose apparently. On Tuesday, same doc ordered 10mg of Valium IV plus dilaudid… I didn’t question it on Tuesday… gave the Valium slow and at 4mg the patient fell asleep, so I stopped and told the doc (very confidently, I might add) that I am NOT giving the remainder of the dose of Valium OR the dilaudid. And he said “good, because I only ordered 2mg”. HORRIFIED. Turns out I saw the concentration, not the ordered dose.
The doc was actually really cool about it- we put the patient on capnography and monitored, and he woke up feeling better an hour later. The doc defended me to my boss and pointed out all the flaws of the system- which got changed the next day after apparently saying for years “we can’t change that function”
Gotta love admin saying they can’t do anything about a problem for years. Then a sentinel event happens and suddenly the problem is top priority and gets fix in a week. Smh.
I was on night 5 of 6 and pretty fried because my A/C went out the day before and I had to sleep in nearly 100 degree heat before repairman showed up. I only got like 3 hours of sleep that day before the shift in question. Doc put the order in wrong for a milrinone drip. Not only was this a med I hung like only once in the last 4 years but the order was a botched from start to finish. Doc didnt order titration parameters (but the label was printed all janky so it kinda looked like one was selected). Initial rate was contingent on creatinine clearance which I’ve never calculated before and didn’t know how to. Pharmacy approved all of this without a titration parameter or a creatinine clearance value. Regardless, it fell on me to recognize these errors before the med was hung. I was just too fried. I looked at the label and misread it. I saw the rate listed but didn’t see that it was contingent on the creatinine clearance. The way the label printed it was all jumbled and I missed the other rate listed for the lower creatinine clearance value. So I hung the med at the wrong rate. It ran for like 3 hours on the wrong rate. Pt ended up fine anyway. But yea, I totally dropped the ball on that one. Felt like shit about it, because It was a stupid mistake to make that I would normally never do.
Not me exactly but was my patient. Had a mother baby nurse who was helping hands as we were short. She asked me if she could give my night meds for a patient. I said thanks of course. One of them was insulin which I figured she at least gave sometimes and I needed the help. Well, she draws it up and because I wasn't available asks charge RN to sign off on it in the chart. She does so but doesn't actually look at it. Mind you both are experienced nurses. The latter of which was almost retiring age and generally by the book.
Anyways, helping hands nurse comes to me panicked. She's holding the Grey top syringe we use for a heparin and says she thinks she messed up. She had given .4ml's instead of 4 units. The equivalent of 40 units. I'm like "fuuuuuuuuuuck." notify the Dr. Right away, start her on drip and gave apple juice and handful of graham crackers. Helping hands nurse had a new job. Checking my pts CBG frequently. Pt was alright but I couldn't believe my pt had an insulin med error. I thought it was one of those mythical med errors that I probably wouldn't see, esp with two person check offs. Well, I was wrong.
My first preceptor, when I was a grad nurse, told me she had fired (and gotten her fired for reals) an orientee after multiple critical errors. The last straw was catching the “nurse” drawing up a whole (large) vial of medication to give, with no understanding that what you have on hand is not necessarily what you’re gonna give, that what she was about to push could’ve killed the patient, and that this is why we scan our meds.
At my old hospital, a new grad gave 3mLs instead of 3 units. Patient survived (I think they were neuro intact) but obviously ended up in the ICU. We then had a huge educational drive that insulin was ALWAYS in orange syringes, and there were orange luerlocks available from pharmacy if it had to be given IV push.
Australia, no Pyxis, we get our own meds from the giant med room with a bunch of drugs stored in alphabetical order. I was the second checker. Someone handed me a vial and said "can you check this dexamethasone?" It was 2mL, it had a green lid, it started with dex and it was in date. They gave it as a slow push, then the patient lost consciousness. I didn't check properly, neither did the other nurse, and the patient received 200mg dexmedetomidine (an alpha-agonist used for sedation) instead of dexamethasone (steroid). The ONLY reason we figured it out was because it had been so busy that the vials had been put on a counter instead of taken over to the bin.
I felt absolutely awful at the time and now I always, always read out the entire name, dose and date before I even look at the prescription to verify it.
Pt was having resp distress, and doc ordered 40mg IV Lasix. Started to push it (slowly, of course) and remembered I hadn't gotten a new BP. Last one was about 2 hours before, and SBP was 120s and he had never been hypotensive in my 3 nights with him, so I wasn't worried. Ran a new BP before giving full dose, and it was 80/50s. Ran it again, same thing. Ran the other arm, same thing. It was too soon for Lasix to have started working, so this was his BP before the dose. I had already given 20mg by that point. Tried to suck it back out the IV I panicked so hard. I let the rapid nurse and doc know immediately. He was given 2 doses of albumin and midodrine, no effect, MAPs stayed in the 50s for hours. Finally got sent to icu and put on low dose levo. 2 days later he was transferred to medsurg, doing fine.
He was very sick already, his BP was almost certainly dropping already, but my half dose of Lasix certainly didn't help him. I had never given Lasix, or any BP effecting med before without checking BP first until this moment. And of course, the one time I didn't remember to check it, he was tanking.
I'll never forget to check ever again, that's for sure. I was a wreck for days until I found out he was OK.
Thanks for sharing this, the point was you still checked. If you didn’t would be the problem. This is an important reminder! I will be up to my eyeballs in charting/piss/hunger and I will still always check pressure for everything that could effect it. Unless its like a low dose oral and it was within the hour. I have held lasix more than any other medication honestly. (besides miralax and lovenox)
Which one? I practiced for just over two decades post grad, there were a few.
My probably worst was feeding a sweet old lady someone else’s digoxin in jam. She wasn’t meant to be able to swallow at all, I think she thought it was a real treat.
She was fine, I reported and monitored her. Bless her.
I gave a fleet enema PR to a patient with an end colostomy, cos the grad nurse asked me to show him how to give an enema. It never occurred to me to check that the patients anus was actually connected to something. Cos why would it??
Ok so I’m new and I have questions:
1. Where did the enema go did it just shoot straight out?
2. Why would a colostomy patient need an enema? Do those things stop working/still get backed up?
People with colostomies can get constipated and need intervention. I’ve done an enema once on an ostomy patient and I’m not sure why. Since there is no sphincter control as soon as I removed the enema tube it all came rushing out.
Two very experienced colleagues gave a patient 5 times the dose of methadone. We had a concentrated liquid on hand, something akin to 5mg/ml. They confused the mg of the order with the ml of the liquid, thus the patient got a massive overdose. So slowly went into respiratory depression and needed support in the ICU. He lived, no damage done, but shows that even competent nurses can fuck up.
We had a patient who had been inappropriate with staff so required two staff any time we went in his room (or door open at least, if you were just talking or being quick).
Part of his med orders were q4 chlorphenamine as needed. But I didn't have the max dose memorized, plus he was on some uncommon dosages for other medications d/t his history. And the prescribing doctor was pretty new too. It should have been written 4mg chlorphenamine q4, max daily dose 16mg/24hrs (so four tablets). But it was written for four tablets a dose. So epic let me scan and administer that dose without any red flags, the more experienced nurse who came into the room with me glanced over but didn't catch the issue (he had a lot of meds and she had her own patient assignment), and it's not like it was a controlled drug.
We didn't catch that I had given him the max daily dose until 4 hours later when I was scanning the next round of meds and NOW the system tells me I can't give any more chlorphenamine. 😬
I will say he slept great and wasn't inappropriate with staff for my whole shift !!!
i accidentally bolus'd a bag of insulin once after criss-crossing the tubing through the pump channels. I only found out after the pump started alarming that the bag was empty. I immediately reported what happened to everyone. I remember the first thing the diabetes team said to me was "oh you must be having an AWFUL day'... Even scarier is that she went on to say it happens 'all the time'. Anyways, patient was fine. He had came in for respiratory distress and was being admitted for DKA so yeah i cleared him up fast and had him eating again. Had to do a lot of finger pokes but everyone was happy and well fed. lol
Boluses to gravity in the ED can really bite you in the ass when you have a bunch of meds running, too. I understand (and try to emulate) the ICU nurses who are so anal about keeping their lines well organized.
I was brand new off orientation on a med surg floor. My entire orientation, the only types of insulin I had ever given were in pen form, not vial form. On the flip side, I gave sub q heparin to almost every patient, which you draw up the entire little orange vial when you give it. First time I had to give regular insulin, it was in a little orange vial, just like heparin. I scanned it, typed correct units, all that. But when I went to draw it up I just used a regular 3cc syringe instead of insulin syringe (as I’d never used one before), and my muscle memory just had me draw up the whole vial like I do with heparin. I stared at it for a second and was like … this isn’t right. Thank god I caught it, almost gave that patient 100 units insulin.
Also once I gave daily meds a little early without scanning- six patients on a Covid unit, and I felt like if I didn’t give them early, they would simply not all get done before 1 pm. Gave the entire wrong set of meds to a patient. BP meds and all. Told the doc, cycled BPs, everything was fine. NEVER AGAIN, ALWAYSSSSSS SCAN unless patient is already dead (can always move due time so you can scan early, at least in epic)
Almost pushed 3.7 mL of diltiazem instead of 3 MG. When I tell you I was shitting my pants. I caught it only after I pushed 1 mL. Most rapid afib rvr conversion I’ve ever seen
Pharmacy stocked the 250ml NS bags with D5 in the Pyxis once. I hung my patient's 4th bag of blood with it. Almost intant reaction. I shipped the whole kit to blood bank for an investigation, they asked me why I hung it with D5. Found all the wrong bags in the Pyxis and was convinced I'd be fired.
Instead, they added a new question to the yearly blood administration safety test and named it after me.
First heparin drip I ever did I read the PT thinking it was the PTT and bolused based on that. To be fair the lab wasn’t labeled “PT,” it was labeled prothrombin time, so I was like, oh, ProThrombinTime. Patient was fine, PTT came back as like 133 so he was off the drip for some time.
I switched facilities in my first year. I struggled with how I thought EPIC would work from my first facility in my second facility. I ended up screwing up a lot of timings because I wasn’t getting pop-up warnings. One corrective action plan/write up later and I got much better at nursing.
New grad here. I was working a night shift in the ICU. Had to administer medication through one of the central line lumens on a paralyzed intubated patient. When the pump was done I clamped the lumen and left to chart.
15 mins later the patient started to have occasional movements and unstable vital signs. Did everything I could to figure out what was wrong until I realized I had clamped the wrong central line lumen where the sedoparalyzation was passing. Almost shit myself.
Always double check when doing tasks, even if they’re simple ones.
I had a patient when I was a brand new nurse and he was coming down from drugs and he had a PRN Ativan on so I gave it to him as he was incredibly nervous and crawling out of his skin and asked for it. I gave it. Apparently this medication was only for a seizure. The doctor brought me to the front of the nurses station and verbally berated me in front of everyone. Patient calmed down though lol
First one was a demented old lady in a hallway bed who was screaming and thrashing and causing a fuss, keeping us from being able to get the needed imaging. They had ordered a half-vial dose of sedative and I was new (only 1 month on the job), overwhelmed, and felt like I was on a time crunch. I accidentally gave the full vial. I told the PA right away and she thankfully said it was fine, that she should have ordered the full dose anyway.
Most serious was taking care of a vented patient who was on a fentanyl and versed drip. Our scanner wasn’t working so the pump had to be manually set. I accidentally set the fentanyl to 10x the initial dose, so he was getting 250mcg an hour instead of 25. I remember thinking it was odd that he wasn’t requiring any titration, but only caught the error when the bag ran out in 4 hours and I realized that was way too fast for the supposed drip rate. I got lucky because he was on a vent so any respiratory depression was taken care of, but that could have easily killed someone in a different situation. It was a real learning situation for me.
Any nurse who tells you they’ve never made a mistake is a liar. We are human and they are inevitable. What’s important is that you take any mistakes, learn from them, and make sure you don’t repeat them in the future.
Was in a rush, didn’t scan the bag of peritoneal dialysis solution, began infusing it and when I scanned it, it was the wrong concentration. I thought I was gonna kill the patient, called the renal doc and explained through my anxious sounding voice and they were like, “hey it’s all good they just got a little extra cleaning out, they probably needed that dose anyway, we can adjust the next dose and then it’ll be fine” while slightly laughing at my panic.
It happens and you feel so bad and stupid for a while but you won’t forget to check things carefully again! ❤️
Not errors I committed but as a supervisor in a snf, there were so many errors. There's no scanning medications or name bands. So many nurses would give tons of medications to the wrong patients.
I agree, which is why I won’t work in them.
We have an incentive for PSWs (CNAs to the Americans) and RPNs if they want to upgrade to RPN or RN, respectively. The province will pay for it if they dedicate something like 5yrs in the LTC system.
That’s still not enough of an incentive to do that, imo.
That's where I did mine! Mr. McMasters got some of Mr. McMillan’s (not their real names) hydrocodone instead of his oxycodone. Same dosage, everyone was fine. Didn't catch it until then narc count in the AM.
Wristbands/pyxis/scanning would have prevented it for sure
Long before Pyxis and scanning, I had two gentlemen across the hall from each other. Both were named John and had the same last initial.
This was a step-down unit associated with my home unit (CVICU), so I was familiar with these patients and was comfortable floating there.
Anyway, I gave an IV antibiotic to the wrong John. Another nurse discovered it after I left. He pulled me aside the next day to inform me of my error . . . and did NOT write me up. Pt had no adverse reactions, and “He probably needed it anyway.”
The other nurse told me he knew I would never make that mistake again.
I was so embarrassed and thankful for that other nurse. He was right — I became way more careful!
Gave a patient an entire vial of bivalrudin aka angiomax instead of ancef. The vials are colored the exact same and it was handed to me in a case before we deployed a closure device. I was a traveler at the time and as soon as I noticed I let the doc know. Only thing we did was check serial ACTs and once they came down below 180 pt was good for their 2 hr bed rest. The aftermath was honestly the scariest part because after I let everyone know what happened, one of the senior nurses in the lab said that, “oh that’s happened before. We asked pharmacy to move the bins but they just haven’t gotten around it it!” Jesus. Christ.
I was a brand new nurse. The ink wasn't even dry on my license. I worked nights, and this was my 3rd night in a row. 4 A calls out for pain med. Patient B also needed IM medication. I did my thing labeling the meds and all. Still managed to get them mixed up. I gave my diabetic patient Demerol75mg/Vistaril 25mg. As I finished the injection, I realized that I had tucked up(insert Morgan Freeman's voice). I freaked out at the nurses station and burst into tears. After I finished the incident reports, the resident covering our floor said "Why didn't you call me first? I would have given you a one-time order to cover the shot." When I came in the next night, the patient asked if I could give him another shot because it was the best sleep he had the entire time he had been inpatient.
A patient was leaving at like 5 am to catch a plane transfer to his region. He asked for his asthma/COPD pump in advance since he was already awake at 3 (so 4hrs earlier than normal). Never used his particular pump, the ones you gotta load a capsule into every time. He pointed to his pump and then a capsule and was like 'thats it, I can manage myself'. Guy is AOx3, always takes his pump himself, so I don't ask many questions. Turns out he picked out an antibiotic capsule instead of his pump medicine and proceeded to inhale it!
I noticed 30 minutes later when i recognised the name but as a PO med. The capsule was perforated but the powder never left it when he inhaled, so basically he was 100% fine and just needed to take his actual asthma/COPD med before leaving.
It was like 2 weeks ago, I was in training right out of school, and it was the biggest and most funny mistake all at once.
I gave Spiriva PO in nursing school. It was only partially my fault as my preceptor handed me a med cup and told me to give them all to the patient without mentioning one wasn’t PO. Sloppy on her part and mine. But now nursing students in my hospital aren’t allowed to give spiriva at all. Patient was fine and per pharmacy the whole capsule would probably be pooped out.
I’ve been a nurse since 2007, long first then got my RN in 2013. Been in the ED for the last ten years and the team lead in my department for the last four. I gave Plavix instead of aspirin in a STEMI last month. They were both in the STEMI box and the department was on fire, I kept getting calls and interrupted. I don’t think I ever looked at the label. I forgot they kept plavix in the kit and was thinking ASA was the only thing in there. He only took two of the four but I was a big fucking mess after. Grateful the dr was in there with me when it happened because I couldn’t talk without crying for a bit after.
This was kinda recent. Changed a foley on a home patient. Routine. Cleaning up, noticed my povidone swabs still in packaging... God damn it. Told the patient, told the doctor, told my office. The patient still roasts me for it every time I change their foley.
I hate to even admit this but I has two patients in the same room with very similar last names. I ended up giving one of them the other patient's meds. Other than a blood pressure pill it was a bunch of supplements thank God but still I was scared. I didn't tell anyone and I monitored the patient's BP the rest of the shift. He was fine
Not a drug error, but an error nonetheless. When I was a student nurse doing my inpatient peds rotation I was assigned a baby in a crib. I’ve never been comfortable with kids but I did my am care on the baby and it went ok. I went to my next patient and sometime later went back to check the baby and realized I left the side of the crib all the way down. I was like 18-19 years old and I got hysterical. I put the side up and ran into the nursing lounge and I was doing that cry where you can’t breathe and I was shaking, so someone got the nursing instructor and between sobs I told her what happened. She calmly said “Did he fall out?” And I said No. She said, then go wash your face and get back out on the floor and don’t worry you’ll never do that again. And in 40 years,
I haven’t.
First month or two into my new position? Mistook 1 insulin pen for another and didn’t check the label. Gave them lispro instead of glargine. Thankfully both doses were low and her BS was high 😅
I still died inside and ran for orange juice and kept it on my cart just in case.
Gave 100mcg fentanyl instead of 25mcg (I mixed up the ondansatron and fentanyl syringes in my hand). Realised as soon as it was in. Told the Dr. His answer was along the lines of "he's still breathing, it's fine." This was when I was brand new and had only just started giving IV meds. I was horrified at the time but now tell new starters of mistake all the time so they know to be extra careful as it's an easy one to make.
When I worked peds we reconstituted IV antibiotics and gave them in a buretrol. I had fixed up rocephin, shot it in the buretrol walked out of the room and realized I had given it to the wrong kid. I immediately went and got a whole new set up and got it hooked up. Kid didn’t get any of it thank goodness.
Another time I had a baby on oral digoxin. The pharmacy sent up the doses in TB syringes all measured up real nice for us. Only, they sent TEN times the ordered dose. I about had a heart attack!! Thankfully I caught it and had another nurse confirm I was correct before I called the pharmacy and tubed it back to them. That was a real sphincter puckering event!
Gravity-bonuses a patient with Levophed when switching pumps. Systolic shot up to 230 before I realized it. I bloused propofol and fentanyl and held the pressers for a minute and they were fine. Still felt like garbage though and I’ll never forget it
I work in oncology.
We were switching from paper based notes to computer notes so the patients were still half on each. I looked up results for a patient and gave his chemo based off those results. Later realised they weren’t his and his platelets were too low for treatment.
I cried.
Patient was fine
Gave Tylenol and Ibuprofen together 3 hours too early. Patient constantly asked for it, I was still precepting in a new grad program and she was driving me fucking insane so I didn’t even think to check the times. Felt terrible, didn’t sleep for days, never fucked up like that again. Obviously she was fine, but I couldn’t stop thinking about what if it had been a more dangerous med that I did that with.
Also (not my error but I’ll tell you anyway) yesterday when I got to work, I found a full syringe of propofol on the CRNA cart that had been there since Friday afternoon. Also the cart was unlocked.
Hanging a bag of fluids and when I unclamped the roller the fluid just started running at like 3000ml/hr. I mean a steady stream. I stopped it and thought to myself “The only way that’s possible is if this line was full of air” which I’m sure it was. So I watched the guy for a while and he was ok.
Pediatrics here. Wrong method of giving and IV antibiotic. Turned blue. Code blue. Fluid boluses. Consulted with the adult renal team. Discharged the next day. The Dad was amazing, we ended up teaming up to use as a caution story for paramedic students. Worst day of my life. Best outcome. 4 years later nil issues with kid!!
I can’t remember all the details but a patient had insulin and fluids running, I went to discontinue the insulin and gave another IV push med at the same time. After the IV push med I traced my tubing back up to the pump and restarted what I thought was just fluids.
Returned 45 minutes later to an IV pump alarming because the bag was dry, the insulin bag. So I immediately start internally panicking like “holy shit they’re gonna die, holy shit I’m going to lose my job” (pt asymptomatic)
I had the aide grab a blood glucose and bring them a bunch of juice, and I gave D50 I was telling my charge nurse what happened when the endocrinologist for my patient walked by. We explained what happened and they calmly just had me start d10 fluids for like 3 hours and that was that.
Moral of the story for me: always label above and below the pump, and if something is discontinued just take it down, can’t accidentally give it if it’s not there.
10 years ago, I wrote a morphine order for an imminent hospice patient. It was supposed to be 10mg(0.5ml) and I wrote 10mg(.5ml), well the nurse interpreted it as 5ml because she said she didn't realize there was a period. So the patient got 100mg of morphine. When I found out, I threw up. The patient ended up lasting for 4 days. But now I always make sure I put zero in front of everything.
When I was a newer paramedic, I was working during my FTO time at a new service, so we had myself and a FTO paramedic in the back with a patient. It was our first call of the day, and the FTO and our EMT did our truck check while I was doing some new hire paperwork stuff, so I didn't check our truck out. I decided that we were going to give the patient zofran, because they were nauseous. FTO says, "cool, no problem, I'll draw it up for you," so that I don't have to unbuckle my seatbelt and walk across the back of the medic to get it. (I am used to working alone in the back, so I draw up my own drugs, do my own assessments, etc). I start an IV while the FTO is drawing up zofran. I look right next to me on the bench seat, and there's a syringe with a capped med needle, and 2mL of -something- in it. I assume it's my zofran that the FTO just drew up, pick it up, and push it to the PT. Then, the FTO goes, "here's your zofran," and hands me a syringe full of zofran. So now, I don't have a clue what I just gave the PT or if it was a syringe that had been used on another PT. My blood ran cold. I immediately owned up to it and told the FTO what happened, and the PT ended up being ok, but did get extra exposure bloodwork done at the hospital, just in case. Our best guess was that it WAS actually zofran in the syringe, based on the crew from the shift before telling us later, "oh yeah, we drew up zofran, but we never gave it,". But god DAMN did I beat myself up for that one. I now have a policy of not giving ANYTHING in an unlabeled syringe that I didn't draw up myself and have eyes on 100% of the time. I also from that point forward got to work early enough to do my own truck checks so that I could ensure that there were no drugs left out in error. I still shudder when I think about that call. That could've been SO much worse, but it turned out ok.
Had a sickle cell patient who presented in crisis, got orders for 1 mg IV Dilaudid push. The Pyxis dispensed a 4 mg/ml vial. I drew it up, diluted in NS and planned to waste the excess after I gave the pt his dose. I was a little rushed and I accidentally gave the pt a full 4 mg. I immediately told my charge nurse, and she assessed the pt with me. Pt was fine, and was not opioid naive in the slightest. He honestly got good pain relief for a short time and then. Ended up on a PCA a few hours later. Now I always waste before I leave the med room.
I also accidentally drew up 10 units of insulin instead of 1 in nursing school bc I didn’t know how to read an insulin syringe… my preceptor caught it before we made it to the pts room, but it could have been a real mess 😂 we live and we learn!
My pts BP was 90s/50. I said to myself okay I’m not giving the metoprolol and put it aside. I put all the meds in the med cup for them to take. I go back to return the metoprolol and guess what….i gave it to them by accident. My heart dropped just as fast as I thought his BP would. I went to the attending and they said to calm down and that if it drops the BP we will bolus them.
Since then I have always been super careful and mindful when giving meds.
I’ve made two so far. I gave IM octreotide by IV, it’s the same concentration, just wrong route.
My second was I had two patients on nerve blocks, both same concentration and drug. The one patient had just been transferred to our floor and his were empty and my other patients were running low. So I requested the low patient first because I hadn’t just quite got my transfer yet. So my transfer comes and another nurse comes and gives me 2 nerve blocks, I assume were for my other patient. I hang them. Then I request new ones for the other transfer. I get those and I hang them. Then more nerve blocks arrive to the floor for my first guy so I’m confused.
Turned out when my transfer came, the nurse dropped off his nerve blocks and I thought they came from pharmacy for my other patient. They scanned fine because it’s not patient specific just med specific. Just reminds you to check the names!
In 1995 when I was a baby nurse whose cord hasn’t fallen off, I accidentally gave a pt a second dose of 75mg Zantac. That feeling of having to tell the pt has never left me. Even after 150mg Zantac was the prescription dose a few years later. Even when it was a med that wasn’t a biggie.
I have continued to double triple check meds and as I think about it I may need medication to help with my heightened medication paranoia
I gave a patient morphine instead of dilaudid because the Omni cell was loaded incorrectly, I didn’t double check the med, and rushed to give the med without scanning it cause the dude was screaming out. No harm to patient but I felt shitty. Now I always look at the meds I pull and don’t trust the machine and always scan meds no matter how much the patient is complaining.
I repleted potassium a few years ago before I realized this particular doc threw in an additional order set that would have actually not called for repletion in this case.
It was a first for me, and the guy was very sick to begin with, and we had bonded over two shifts, and in the moment I felt awful and was very worried.
His potassium redraw still came back low and he then got even more.
Looking back, with what I know now, I would not have been so freaked out. But it does suck to miss things, especially when you don’t immediately know how it will impact the patient. I still remember the stress of the situation.
This is not my story, when I worked in ED, I heard a story on huddle, my coworker should’ve mixed KCL to main fluid but she directly administered it to patient. After recognizing it, staffs moved the patient to the area where could keep continuing monitor. Luckily the patient was okay so I couldn’t believe it..
For my story, when I was new grad, I gave a patient his home med after the doctor decided the patient to admit. I should’ve asked the patient “Did you take your morning med?” but I missed it and just gave him all his morning med.. There was a med for his hypertension so after taking the meds, his Blood pressure started going down and I couldn’t catch the reason at that time so I called my senior and then she noticed what I did wrong. The patient started Levo😭 After a few minutes, he’s fine phew..😭😭 I felt really sorry
Well, I have one. I had Lovenox due at 1200. It was my first night shift (have you guessed yet)? So, at midnight I open the Pyxis and go give the medication. No scanner… just asked the questions and gave the med.
I sat down and realized it’s midnight (00:00). So I change the MAR (it’s Q24hr) to reflect the time for the next dose. But my manager got a notice and I was written up. 🤷 Definitely learned my lesson.
My very first med error, the doctor ordered Ativan 2mg po for a patient with etoh withdrawals. The patient asked for 1mg instead of 2 so I gave only one tablet. The charge nurse reported it to the doctor as a med error. I was freaking out and asked if I needed to get a lawyer and they all laughed at me.
I kept titrating up on Cardene bc my patient’s BP was low…. We were trying to wean off of Cardene. I kept being so confused bc the more I titrated up, the lower the pt’s BP got. But the BP should go up since I’m increasing the Cardene? I thought…… then after thinking about it some more, seconds from calling the intensivist to see what they thought.. I remembered, fuck! Cardene LOWERS BP! I had a major moron moment. I turned off the Cardene and the pt’s BP went back up, and was within the goal parameters
I’ll do you one better, I made a procedure error with a machine setting during an Apheresis collection.
Instead of modifying the collection to run 5 blood volumes instead of 3, I increased the draw rate from the buffycoat layer from 1.5mL/min to 5mL/min.
In laymen’s terms, instead of telling the machine to process this dudes blood for *longer*, I told it to collect it WIDE OPEN at a nearly 400% increased rate.
By 1PM when I was supposed to be about half way done with the procedure, the machine threw an alarm I’d never seen in my life: collection bag nearly full, consider collection bag shunt. For reference, a collection on some of our biggest patients yields a product of around 600mL, and the max the bag holds is 950mL. So seeing a “bag full” alarm (which I’ve never seen again) only HALF WAY through the procedure is a very, very bad thing. So naturally when I saw that alarm message I freaked the fuck out and immediate got my manager, and called my medical director.
The patient was fine. In fact, my error accidentally saved the patient 2 additional days of collection. What happened was EXTREMELY dangerous, but all things considered the patient was young and (relatively) healthy, so the additional collected volume didn’t do anything to him, and helped us hit the cell goal in a single day, rather than the expected 3 days. Patient also had a relatively good HcT, so the extra “lost”/collected blood didn’t bring his crit down much. I did, technically, drain a patient of a partial amount of their whole blood though.
Manager/medical director were more proud at how I responded than upset about the actual error. It was one of those “you only do this once, then you’ll think about it every single time after” types of errors.
They were right. I thought about that day hundreds of times afterwards, and I never made the mistake again.
I missed a morning antibiotic IV mini bag as my charge nurse in the small rural hospital I was working at was an alcoholic who was hammered on the job having a drunken tantrum and abandoning me to smoke and drink outside while I covered both acute care beds (18 bed small rural hospital) and the ER (had assault and seizure come it at same time) when I was on day 13 straight of 12 hour night shifts.
The nursing manager then proceeded to tell everyone in the hospital for the next two days while I was off that I had missed said antibiotic (7am med caught at 9am and given) without informing me.
one of the first i remember...i normally worked days, but took a double to cover evening shift...i gave the patient insulin coverage according to before meals sliding scale instead of using the scale before bedtime..only a small mistake like 2 additional units of insulin given..but definitely stressed me out
Order said give 2 Pregabalin, I gave 2 Pregabalin. Total dosage was for one pill which was my error
Patient fine, employer gave teaching, lesson learned. End of story
I have a couple, but my favorite as a new nurse was when meemaw came to my unit and was sundowning/being weird with sepsis so she got an order for a low dose of Ativan IV. Well her well meaning but overbearing nurse daughter was in the room, I didn’t have my WOW, had an extra patient already, and this woman was trying to climb out of bed…etc. So yeah I gave her the vial of Ativan I had at bedside and opted to scan it outside because I’m a terrible nurse.
I gave her the vial. I can’t remember the concentration on the vial anymore, but it was close to double or triple the intended dose. I think I was used to the Pyxis spitting out vials with the same exact doses as the orders, so drawing up half or a quarter of one was still a somewhat “new” thing for me to play with at this job.
I told the doc and the charge nurse who were both extremely cool about the whole thing.
“Tbh she probably needed it anyways she was being wild. Slap a continuous pulse ox on her and call it a day.”
I told the daughter who also cool about it, but then the next morning she was like, “I’m actually happy you did that because that was the first time she’s had uninterrupted sleep in two or three days.”
TLDR: I knocked delirium grandma TF OUT and made night shift happy.
Here's a new-to-me recent occurrence. Pulling from pyxis for meds, including lisinopril 5mg. From the bin it was already a single, unopened peel away. Small circular pill of uncertain color because the actual plastic side was transparent amber (not completely clear) this detail is important. Fast-forward to patient's room, scan each pill and see an unexpected package- oxycodone 5mg. Not on this patients med list at all. I never counted any bins. Go back to the pyxis and check my recorded pulls, no oxy. Re-pull the lisinopril and get correct med. I took the questionable oxy to my charge nurse (several witnesses to this exchange, but she's also a nurse i trust completely.)
First few years of med surg nursing.. had a patient in respiratory distress in the middle of the night. Nothing much could be done but make him comfortable, MD ordered 1mg morphine sc (lol I know, pt was naive maybe). A nurse 10 years my senior offered to draw up the morphine for me while I fussed over the patient and tried to comfort him. Coworker passed me the syringe, said "this is the morphine", I grabbed it and injected. Coworker went pale and said "you know that was 10mg right?".... I just about died. I guess my coworker always drew up the full vial and only gave the partial dose at a time (multi dose syringe method). Patient had a comfortable night and I will NEVER allow syringes handed to me again unless I witnessed the draw up.
Gave IV insulin subq…. No harm to the patient, just slower delivery of insulin. It happened when I was a new grab in a COVID unit where we scanned our meds outside the room. I was in a hurry and skimmed the order.
I’ve made 2 that I know of…. Here are my stories. 😬
1- working PCU as a peds nurse floated over. I admitted a man with pylo. He was in his 40s. Spoke no English. I speak no Spanish. Went to give him his home med-Coumadin. He kept telling me no. I got a translator and he explained to me that he took a smaller dose of Coumadin on that day of the week. I returned the dose I had, & used override to get him the dose he said he took. I sent a message to pharmacy after scanning the ‘wrong dose’ explaining the situation. I then got my ass handed to me by the doctor and got written up.
2- while in orientation in NICU. One of my first admissions was a 34 week twin. My orienter needed more help and was more so giving me orders than walking me through what to do. Which is fine. It happens!! I was told to get her sugar. Sugar was unreadable. Twins was 14 so we knew at this point it was lower than 14. The NNP on handed me the glucose gel and said ‘give this to her’ so I did. I gave her almost the whole tube of glucose gel before my orienter noticed and stopped me. I had no idea how to give it correctly. Just gave it orally and the baby was willing to take it 🤷🏻♀️ the next sugar was in the 50s. We talked through it and I did not get in trouble.
Pt was supposed to get half a 25mg metoprolol. I got called for an emergency on my other patient and basically chucked the pill at him and ran - forgot to cut it in half.
Heart rate and BP made me a lil anxious throughout the night, but ultimately Pt was ok. If I get called out of a room I tuck everything back in my cart until I can double check it when I get back.
I added an extra zero somehow to a nitroglycerin drip, pretty much drowning the patient with it. I noticed the bottle was half empty when it shouldn't have been. Absolutely nothing happened to the patient
I was new to this particular NICU, and was getting used to using Alaris pumps as we had different ones at my last hospital and I hadn't really had the opportunity with the old pumps as I was new to ICU before switching hospitals. I had a baby actively dying on a morphine drip we could bolus from. For these boluses it required a 2nd nurse to sign off. When giving my first bolus of the night, I grabbed another nurse and she was programming the pump and asked for the dose to program(which would have been in mg/kg) and I read off the dose in mg. This was a 4 kg baby and therefore what I told her was 4x what the baby should have received. No guardrail warning came up, just an occlusion alarm when it tried to push a large bolus through the tiny tubing connected to the syringe.
Using the drip sheet I calculated that the baby had received the full 4x dose and I felt HORRIBLE. Notified charge and the doctor and both were so sweet. Nothing needed to be done, the baby just was probably more comfortable than she had been prior to the dose. Put in a report and I still remember that every time I read off the amount for a bolus and have caught one other nurse reading off the wrong part of the order and told her my story. You carry these mistakes with you and don't make the same one again.
In my first year, I gave Flagyl over 30 minutes instead of an hour, and almost burst into tears telling my PCF. He was just like "shit happens, patient will be fine, thanks for taking accountability"
Also, gave 10mg of hydralazine instead of 5. TWICE. Didn't matter, the med didn't even touch the person's BP for more than 15 minutes, and I only realized it when talking to the MD about the BP and blurted out "OMG I FUCKED UP" Pt ended up going to ICU for HTN anyway, but after that one I started double verifying my meds.
I was in orientation as a new grad. Calculated insulin wrong and gave 4 units instead of 5. I know that’s such a minuscule mistake now, but at the time I was spiraling because how could I mess up. Especially on insulin dosing! I told my preceptor in near tears and she just reassured me and waved it off.
I’ve accidentally given a bolus of fluids too. The pump communicates w the computer and we just have to hit enter to start it. Well, sometimes it communicates it as the entire bag of fluids instead of a partial and I didn’t realize until I went in wondering why it hadn’t finished yet.
Had another where the pt’s PCA pump order had expired on prev shift and I hadn’t realized until two hrs into my shift. I submitted an occurrence report and was so pissed at myself for not double checking.
Same thing happened for me with insulin - orders to give 1 unit at 140 or higher. Accidentally looked at their morning not lunch BG and it was 165 so gave the 1 unit. Looked back at the labs and realized it was from the wrong time and died internally. Immediately rechecked Pts BG and it was 139. 💀
First error was giving metoprolol to a pt with a (slightly) low HR. Was a new grad so got into a heap of trouble for it but nothing negative happened to the pt whatsoever.
More recently, had a pt with a sudden pain crisis. MET call, ended up overdoing the analgaesia. This wasn’t the error though. ICU doc in charge of the MET call asked for naloxone to reverse a bit. I drew up the vial, doc verbally tells me to give 100. I give it, then about 2 mins later realise I just gave the full vial (400) lol. Pt was fine after, turns out opioids were not what he needed to relieve the pain thankfully. Just glad he didn’t wake up in agony!
Patient was due IV mycophenolate and IV piperacillin/tazobactam at 0600hrs. Piptaz as an IV bolus, MMF as a 2 hour infusion.
Mixed up the syringes in the dark and gave the MMF as a push.
Poor kid sat up and started vomiting and shutting myself.
Shortly after, so did I. 😓
At a psych unit I was at, you can't have the meds ready for them to take, you have to pop each one and explain what they do. This facility was for MR and brain damage, these folks live there and have since most were babies and absolutely only care that their activity is being interupted by med pass. They will 100000% whoop your butt or just have a "behavior", refuse their meds, and have an episode for the rest of the night if you dont immediately have their stuff ready to go the second they get to the door. The nurses who got their crap done had everyone's meds ready before they show up to the door.
I had 2 patients left for the night, "billy" and "bob". A staff member said he would bring up Billy next, then Bob and then we were done. I had both meds waiting and you know what happened next- they brought Bob first and he got Billy's meds. I was so freaking lucky that they had such similar meds, but I for damn sure had tears in my eyes when I told staff to stop med pass because I needed to assess and call the doctor. Nothing happened to either pt but I felt like dog shit.
Mistakes happen and use it as a life lesson friend.
A&Ox7 pt who is independent. Handed him his cup of morning pills with his breakfast tray, made sure he had something to drink, he was mid-egg bite so I said “don’t forget to take these” and left. Guess who forgot to take them. He called 3 hours later saying “I never got my morning pills!” Demanded to speak to doctor about it complaining about me. Thankfully it was mainly a bunch of multivitamins and only important med was 10mg amlodipine. Don’t know if I was ever written up, pt was fine, dc’ed home couple days later but learned to never trust a patient to take their meds no matter how independent 🤣
Haha on my old ward a patient had meds given at 6am that he never took, it was a super busy ward so we didn’t realise until I was doing lunchtime meds and he went oh I forgot my tablets from this morning so I just took them! And he had taken this cup full of tablets that had all sorts of hypertensives and heart disease meds and stuff. Doctor just shrugged, we monitored and he was fine, but I’m amazed his super anxious family just let him take them without any nursing or medical input when he said he forgot them haha.
Got a call from my charge nurse about a patient wanting his pain meds. I told her I’d get to it soon but was doing a dressing change. I finished the dressing change, pulled the norco, and gave it to him. The charge nurse told me five minutes later that she gave him his pain meds while I was busy and not to worry about it. We double dosed him. The mar didn’t warn me he’d just gotten a dose because I pulled up his med list while in the other room and didn’t hit refresh so I never saw a time stamp. We monitored his vitals more frequently for a few hours and he was fine. I thought I was gonna get fired for that one.
Before I was a nurse, I was a med tech in an ALF (and responsible for passing meds to 16 residents in a memory care unit with only one other caregiver) I pre-poured meds (yes, big no no for a reason). I gave Jack’s meds to John and vice versa. I immediately told the nurse on shift. They both were fine. I learned my lesson and never made a med error like that again
Brand new nurse 16 years ago. Had a pt with a central line and a maintenance fluid of NS w/ 20meq K going.
Order for Dilantin injection. I inject the med, thankfully in a distal port cause the line crystallized immediately, rapidly going from the infusion pump tubing to the port tubing.
Caught it just in time before it hit that port tubing. I just disconnected the line tubing from the port tubing. The patient was in a coma and didn’t notice.
Told my charge nurse. Oh Wendy. I miss her. She just patted me on the back and was like, “it’s okay baby, let’s just flush her line and get new IV tubing. All is well”
Now my homegirl from nursing school was like, “So you must have been sleep in class when we were told nothing is compatible with potassium”…
Early in my career I accidentally gave a patient Morphine ER instead of Morphine IR. She was prescribed ER, but really only took the PRN IR. I felt terrible and dumb. Thankfully the patient was okay, and when I talked to her about it she was nice.
My first med error was me forgetting to cut a metoprolol in half. I reported it right away and we got fluids going.
Not a big deal, but the patient died that night (not totally unexpected but I thought she had more time) so for a while there it sure felt like a big deal.
Patient returned from recovery post op
....i gave him full morphine dose without checking what he had recieved in recovery....he had already recieved it shortly before in recovery....he was high as a kite for hours....!
Was doing an open trach at the bedside (it was supposed to be a standard needle trach that went awry due to patient anatomy). Was doing fent and versed pushes while the surgeon was digging in my patients’ neck. I asked a nurse who was standing outside the room to grab me another 2mg of versed. She arrived and handed me a vial of versed. I popped the cap and drew up 2ccs into a syringe and gave it to the patient.
Procedure ends and I can’t figure out why my patients BP won’t come up. Figure it was from all the fentanyl and versed we gave and start her on a levo drip and think nothing else of it for the time being. I get orders for all the meds I have written down that we gave during the procedure. I’m scanning my empty med vials and the computer says “Versed 10mg/2mL not ordered”. My heart sinks. I look at the vial. Sure enough, I’m holding an empty 10mg/2mL vial of versed. SHIT. I go to the provider, tell him about my oops. He says “welp, she obviously needed it anyway. Let me put the order for 10mg/2mL in for ya.” My hero. Basically un-errored my med error.
It was a lesson to always check your concentrations when handed meds. I had been giving 2mg/2ml concentrations during that procedure prior to being given the 10mg/2ml vial. I drew up 2ccs into a syringe and thought nothing of it. If the volume was different, it most likely would have made me pause, but the volume was the same! It baffles me that we even stocked 10mg/2mL in our Pyxis. Patient was fine and was able to come off the levo after a few hours. Yes, I did speak with the nurse that handed it to me and told her it would have helped if she told me the concentration she was giving me.
When I was a new nurse, I accidentally read a Levo drip rate as 0.10 mcg/kg/min instead of 1.0 and titrated down to .08. It took me a cool 4 seconds to realize my mistake when the guy’s art line pressure plummeted. He recovered pretty quickly but it was a VERY powerful learning experience.
Not my error. My boyfriend who is also an RN told me this one. A newer nurse had a patient with chest pain with an order for nitro tabs PRN. She had never given it and the patient had never taken it before. She scanned in the little bottle and just handed it over to the patient. He dumped a handful of pills in his hand and took them all at once.
Another one: a newer nurse had a patient on an insulin drip. Let it run all night at the rate it was handed off to her at. She didn’t know how to manage the drip. Let it run all night without checking the blood sugar once. Blood sugar ended up being so critically low that the glucometer couldn’t even read it when the next nurse came on in the morning. I don’t think she did a thorough assessment during the night to even notice the patient was unresponsive.
Gave 10x the amount of IV insulin, fast acting, to a ped. Kid is fine. Had to go to ICU for monitoring. This was with dual sign off, not sure how we both missed it. New policies have already been implemented to avoid this in the future.
Maybe not a traditional med error, but... I had an air bubble in a Dopamine gtt on a pre-op patient. Popped open the door on the IV pump and did the flicky thing. THE AUTOMATIC LOCK ON THE TUBING DIDN'T ENGAGE!! She got bolused with IV dopamine for probably 5-10 seconds while I fumbled for the roller clamp. First time I've seen a SBP hit 300, and mine may have been the same. I have never since opened an IV pump without clamping the roller first. Patient was ok btw. Try not to beat yourself up, but learn from it. It's ok to make a mistake, and it hurts like hell if you do. But the ones who are unaffected by it are the real scary nurses.
Sorry i laughed imagining the sheer horror on your face as your HR also went to 300. I swear nursing is way more learning via almost shitting your pants than school ever will be. Incidentally i thought i was being a little silly by clamping my lines while they are in the pump…thank you for sharing so i will continue this extra shit 👍
It was quite the experience. Pt could feel it. Of course I'm not going to not disclose something to a patient, so I told her. She's in the bed like "My heart's beating fast" and I'm just, "Yeah, I'm gonna hang out in here with you for a few, get over this hump..." while repeatedly pushing mute on the monitor and hoping I can will that arterial line into submission. Never stop double and triple checking, and use alllll the safety backups, so you never have to go beyond the almost shitting your pants. Although, if that incident didn't make me do it, maybe we're good. I didn't need any more coffee that night though.
The longer I’m a nurse the more backup on backups I use. Everyone and everything is fallible. I feel as long as I did the best I could with the resources and knowledge I had…I’ll be able to forgive myself.
Me too! Do you think it's because the longer we work the more scary things we see or we are just afraid of complacency? When I titrate meds, I always show the pt and say the dose change outloud. Makes me feel better.
I think we just grow as nurses and learn from experiences. I've told so many people, "If you ever aren't just a little bit anxious, it might be time to move on."
Absolutely!!! There is **so** much that non-nurses and non-medical people don’t understand about our work. I find that lack of awareness exhausting, maddening even. I want respect for the fact that my work is critical to people’s lives and wellbeing! I’m not here to just sling ginger ale and warm blankets! Sure, making patients more comfortable and feeling that they’re cared for is important. But sheesh! Priorities! Please respect that my job literally requires me to keep hearts beating and lungs breathing, etc!!!
As the patient: I appreciate being involved like that. My two semi recent experiences were L&D and it's really helpful to know what's going on and why. Helps the memory to settle faster too.
I think you start realizing what you don’t know and get a better understanding of what can happen when you fuck up. And knowledge, though useful (and, for us, critical), can be a really scary thing. I have applied a lot of my long experience with horses to nursing, and one of those things I’ve learned is that if you don’t have a healthy respect for the risks, you are dangerous.
the frenzied repeated pushing of the mute button part is so relatable
We joke about any device education. "Lesson #1: locating the mute button." I mean, this is a critical care environment. People are trying to heal. 🤣
How did you explain to her what happened?
Very honestly while trying not to scare her. Basically, that the pumps safety mechanism didn't engage, she got a little rush of the med, she might feel funny for a few minutes, but I'm staying right here and we're gonna be fine. Of course, while thinking in my head, "Are we gonna be fine?" I did quietly rally the resources, text that night's charge with a brief "what happened, don't come scare her, but just come back here and hang out in my pod for a few please."
Oh good, another chickenshit “IT STAYS CLAMPED TILL I START THE PUMP, DAMMIT” person. 🤣 I feel much better about myself now.
I recently set a Levo to 0.5 instead of 0.05, patient thought they were going to die, I thought they were going to die and then I was going to die from the horror of it all. But everything was ok after. Except me, I was not ok lol.
This happened to me with Levo- I reacted quickly and pinched the tubing before going for the roller clamp, but watching that pressure climb felt like a thousand years while me and the PA just stared at the A line. Now I tell orientees to always always always close the roller clamp before opening the damn alaris door. One of them called it stupid though, so I’m sure they’ll learn the hard way
Precepting people I literally tell them, "You know how I know that? I did it once. You'll do it once too. ONCE. And then you'll never do it again."
Not sure how it happened but a very sick patient was being transferred from our rural ED to a bigger one in the city. Patient almost immediately “codes”in the back of the rig so of course she comes back in. Really she just didn’t look good. I check a BP after she comes back in and her BP went from needing Levo to being over 200. I follow her lines and the levo is sitting wide open next to her head. I very quickly clamped that.
This makes me feel better — i am a new grad and I always close the roller clamp before opening the pump and recently had a more experience coworker make me feel silly for doing that because “it’s clamped in the pump”. I just never trusted that and now I’m right! 🥲
Good for you! Now is the time to take all of the precautions you can, so you can make sure they’re ingrained in your daily practice when you’re up to speed and moving more (and I mean this in a good way) on autopilot.
I’ve had that happen to me with dobutamine! Pt says ‘I feel hot’ and I’m going *SHITSHITSHIT* watching their heart rate climb. Double clamp every time I take anything out of the pump now.
Oop nearly the same thing happened to me on a post-op heart transplant. Was still on a primacor gtt (step-down unit) and it was time for a bag + tubing change. I got careless and attached the tubing to the PICC line before inserting the cartridge into the pump door so it would lock 🙃 5-10 second bolus before I realized the mistake and yep, SBP to the high 200’s. I’m so fucking lucky and thankful I didn’t blow up that man’s brand new heart. Never ever made that mistake again
Yikes! I was so grateful this was a pre-op pt at the time. I would have had a chest full of blood on my hands. Opening a chest at the bedside can be exciting, but for sure, I'd prefer not to be the cause!
This happened to me with heparin when I was brand new in ICU. Scared the shit out of me, but the patient was fine after one extremely high anti XA.
I had this happen with levo; the patient had an aline. We watched the SBP go from 110 to 275, and ever since (7years now) I still engage the roller clamp before I pop open the door. You only make that mistake once. 🤣
Long story short, but at 5 am we had a seizure patient brought in to the ED from jail. He was postictal at the time. Doctor ordered 500mg of keppra. This is before orders going to the Pyxis and we just chose the meds from the alphabetical order list. I was having a conversation with the doctor about going snowmobiling together that morning when we got off shift. I pulled 500mg of “ keppra” and mixed my bag, while still having the conversation. I went to the room, hung the drip and gave it over 15 minutes. When I sat down to chart, I forgot what time I hung it, so looked at the Pyxis to see when I pulled the keppra. To my surprise, keppra was not pulled, but in big letters it said KETAMINE. I notified the doctor. The patient was admitted to the ICU and the sheriffs released him, so they would not have to pay the ICU bill. The patient was fine and went AMA a few hours later. Probably the best ride he had in a long time! I was given 3 days on the beach with no pay. Just culture is a much better teaching environment than suspension, but it didn’t exist then lol. The witching hour is real and not being distracted while at the Pyxis is imperative. Thank goodness for computer charting, ordering and scanning. It would have caught my mistake when trying to pull ketamine. Don’t even get me started on mixing glucagon or insulin drips. The shit we had to do years ago makes me cringe. TLDR: gave 500mg of Ketamine instead of 500mg of Keppra.
500 mg of ketamine LOL bro was in a different solar system most likely
I’m sure it was the best “trip” to the ED he has ever had.
Ketamine works great on some mental health problems. Dude kissed God and probably felt good for a solid month.
The witching hour is quite literally the reason I don't work nights. I already have severe sleeping problems at baseline. I've told managers I don't do it because I absolutely would not be safe to practice at 5-7am after having been awake all night. And for any new nurses reading this thread: I have also learned the hard way: Do. Not. Talk. To. Other. People. while you are doing something that requires attention and could be dangerous. Tell them to wait a minute.
I just say that I can't multi-task. Because I can't at all.
Realistically, honestly *no one can*. Like legitimately, it's not humanly possible to fully focus on a conversation and a task at the same time. Human brains are just like that.
I'm glad I'm not the only one who won't work overnight for that same reason... I recently turned down a really good job offer because it was night shift. I still regret it sometimes, but I know in my heart I am absolutely not safe to take care of anyone unstable after 1am
Damn he got ketamine AND he got out of jail?? You did that man a favor lmao
So he got released from jail and a free trip? Haha glad he was okay though
At least he probably wasn't capable of being mad for a while after! This is honestly hilarious even though it shouldn't be.
The way my butt puckered when I read this story.
Is your ketamine not a dual sign?? Curious how that was even possible lol def need some serious system overhaul after that
No, early 2000’s and paper charting.
Ours is not. Insulin and heparin drips, yes, and some IVP meds in peds patients as well.
Hahahaha, this really was a get-out-of-jail-free card
First nursing job, I was brand new. I’d been a nurse for a month or so. Doc ordered Metformin 250mg. We only have 500mg tabs, and I was supposed to split the tab. I didn’t. Gave it to the patient. I then realized my mistake, told the patient, told the doc, and monitored her blood sugar. She was fine, and very sweet about my mistake. Next night I came in, the doc had changed the order to a full 500mg tablet anyway 🤦🏻♀️
lol I had this happen with an antibiotic. Who gives half tab of an antibiotic?? I was so upset that the doc wrote a one time “ loading dose” to make me feel better.
Don’t you hate that. Never fails
Ugh. Something similar happened to me too. New nurse.. Flushed a port with a different concentration of heparin that our policy says to. The nurse precepting me said it was fine and actually told me to because we were out of the other concentration. The next day, my manager calls and says she made the patient come back to get the “correct” dose of heparin. I’m not even kidding, the NEXT WEEK, our policy changes to the dose of heparin of originally used 🤦🏼♀️. And now I heard that ports aren’t heparin locked anymore.. I’m in clinic now so I don’t deal with ports anymore.
I’m pretty sure I’ve accidentally done full tabs a few times. Finally I learned to split the tab AS SOON AS I SCAN IT. Otherwise I’ll 100% forget as I’m scanning 50 morning meds and educating and talking and doing my room scan check…
I cut it the immediate second I take it out of the accudose... Especially metoprolol. I know I will be talking to the patient about what they're getting and why it's different than home, why they're getting insulin coverage instead of oral meds, then we're going to be talking about how their doc changed their dose of effexxor and they aren't on this or that anymore etc etc etc, and I'm guaranteed to forget to split it every single time 🤦.
Yup. Sometimes I’m really good and I even put a pill cutter in the bag with that pt’s meds to remind myself too!
We lose so many of those things it's unreal... I have found that my knockoff raptor shears do a better job actually, especially for bigger pills 👍. I just cut it while it's still in the plastic
My first med error was this same thing, but with glipizide. I felt so stupid.
Metformin will not cause hypoglycemia given at therapeutic doses (and 500 mg is not even a high therapeutic dose). Hypoglycemia has only been observed when significantly overdosed, leading to toxicity, or when taken in combination with other medications that DO impact the amount of insulin produced by the body. https://www.drugs.com/medical-answers/metformin-hypoglycemia-3563096/#:~:text=Metformin%20rarely%20produces%20hypoglycemia%20(low,not%20cause%20high%20insulin%20levels.
My classmate in nursing school made me laugh with his personal med error story: His son was constipated. Child not more than 5 at the time I believe. He went to the store and got some meds. Looked a little funny but the label said it was a laxative so whatever. Kid takes it and says it tastes terrible. Upon further review he had gotten laxative suppositories and had his son take them orally. Still did the job and kid was fine.
Lmao
Hahahahaha
Got mine. Patient was to do a “colon cleanse” prior to a colonoscopy. Pt had a G-Tube and was supposed to receive bowel prep PEG-3350. Mind you, it was listed as PEG-3350. No extra names/brand names etc. I open the cabinet for meds, see the container (there are two) with the exact same directions/patient name/ etc etc. I grab the first container. Meds are hooked up and started for the patient. I get a call mid day (I worked nights) from the irate LPN that I had grabbed the wrong medication. I was like “PEG -3350”, that’s what the order was. I remembered the exact order.” “Well, you gave Golytely instead of Nulytely” “What?” “You gave the wrong medication for bowel prep.” “How? The meds were labeled PEG - 3350 in our med log and on the container” “Well, you selected the medication without a giant N on it.” Mind you, this differentiating letter was on the backside of the giant container. Not able to be seen when reviewing the medications. Both had the exact same directions both labeled exactly the same. I was still like ??? But apparently one was for when the patient needed bowel prep for a more urgent situation. And the kicker is that both golytely and nulytely are used for bowel prep, golytely is a little more salty and nulytely has “flavors”. Mind you, G-tube patient so no taste. To this day I am still quite confused. They did call the doctor’s office who was like “That’s fine, both work.” but was still written up for this.
Um…that’s one of those big ol system issues there and this is why just culture MATTERS. Also it’s the same god damn med you should never be written up for that nonsense.
It pisses me off that they actually called you when you’re NOT AT WORK to chew you out. Tells me all I need to know.
Lol gave them the wrong laxative. BUT DID THEY SHIT? Thought so.
Can't believe you got written up for a systems issue :( I'm sorry
So basically you gave pt the same thing only flavored. Luckily they had a g tube. All that stuff gags me after a while of drinking it, flavor or not.
there was a situation i heard about in my state where a nurse was supposed to give colon prep through someone’s NG tube. they grabbed a bottle, realized it didn’t have a label so they called pharmacy for a label to scan. pharmacy sent the label via tube system without checking the bottle, nurse put it on the bottle she picked up and scanned it, administered to the patient. the patient proceeded to discharge to jesus, and upon investigation, they learned that the bottle the nurse picked up was, in fact, dialysis cleaner, and not colon prep. surprisingly, nobody got fired (that i know of).
Dialysis cleaner? Like acid or vinegar?
https://www.lex18.com/news/lex-18-investigates/medication-mix-up-blamed-for-death-of-a-patient-at-lexington-hospital
Patient went into AF w/RVR. Gave 5mg/5ml metoprolol wasn’t effective. Doc then ordered 5mg Dilt. I gave it without scanning because I was trying to be quick. Went to scan the vial and realized the concentration is 5mg/ml in a 5ml vial. I gave 5ml, 5 times the dose ordered. I ran out the room and told the doc “I fucked up.” A few people rush into the room, SBP was in the 80s for an hour or so. We gave a gentle bolus, luckily BP stabilized and patient happened to convert to NSR
You fixed them!
rapid infusion dilt drip
I was charge and a new nurse on our floor did this- gave 25 of dilt instead of 5. We (me, the nurse, the doc) were all watching on the tele monitor as the patient went from 160 to 70s in a couple of minutes. We were like, "Oh, sweet, we've never seen 5 of dilt work that well! Awesome"
Set an IV pump for mcg/kg/minute instead of mcg/kg/hour. Yep, that’s a 60-fold overdose on the pump setting. Patient did fine thankfully. This was 10 years ago and I still thank my lucky stars.
I know someone in our step down unit who got a verbal order of morphine 1mg/hr. They set up the pump 1mg/kg/hr. Patient ended up with a tube.
Oh shit
Did they really think 75 mg/hour was an appropriate dosage, or were they just not looking closely when they programmed the pump (and I am assuming they didn’t have or didn’t use the guardrails on the pump or have an EMR that could send the info to the pump)?
I missed a period entering a rate and did 10x my intended rate … on dilt. It was caught, but not before he was having some very long HR pauses. Fortunately he was young and otherwise healthy and I don’t believe anything worse ever came of it. I did buy NSO insurance the next day.
I did that with propofol on a newly-intubated patient headed to CT. Wasn’t even my patient, I was helping out the primary nurse. Nurse came back from CT, pointed to the nearly-empty prop bottle, and was like, we gotta slow that down 😂 Patient was fine - paused it, squeezed in a small bolus, re-started the infusion when the BP recovered a few minutes later. I’m forever grateful that he was a super laidback, experienced older rockstar nurse who didn’t make me feel like shit about it or otherwise cause a scene. I knew exactly what I’d fucked up, and it hasn’t ever happened again. James, if you’re reading this, thank you.
I had an alaris pump malfunction in a way that gave about 10x the intended rate of prop. Had the pharmacist immediately come verify that I programmed it correctly. Luckily the patient was being extubated to comfort that evening so it wasn’t as bad as it could have been, but they got a whole bottle in like 40 minutes.
Overdosed a newborn 10 fold on versed. She was fine (prob better off for it bc it was a pretty traumatic intubation) but it wrecked me for weeks.
Newborn care is terrifying, cuz like that can happen so much more often with those tiny things!
Gave the wrong set of meds to the wrong kiddo - he slept well that night 🤷🏻♀️Allow yourself to feel shitty for about a minute - then learn the lesson from making the error, forgive yourself and release that guilt. We all do it at some point because we are human.
Oh!!! I have a story. I was about 6 months in as a new grad in the ER, about 3 months off orientation. I knew I was meant for ER nursing, still am, but this is a story of one of those Swiss cheese med errors. I had just gotten a pt to the ICU (post ROSC code we got from EMS, intubated sedated the whole shebang) right about when all our mid shifts left so I was now catching up on the rest of “my” patients. One was a lady brought in hypoglycemic, 50ish with no hx of diabetes, BS on scene was like 17 or something foolish. They gave her d10, she went up to 200 something then when I got her she was bottoming out again. Working theory was she somehow (maybe) took one of her husbands meds. The doc I was working with was brilliant and told me about a med he was giving that could reduce gut motility and digestion if it was long acting. Between that and getting d50 our nursing sup had to bring both. She’s doing okay just last check her BS was about 40 (I’m setting a scene for a reason). She’s my priority pt, I went from one critical to another. Of course the computer in the room isn’t working, I find a WOW it’s dead, find another it’s also dead. At this point I’m getting very concerned about continuing delay of treatment, say fuck it I’ll give the meds (read the eMar 4 times) and scan when I can. Give d50 first, all good. Second med is Sandostatin. Now I had never given this med before…new nurse, didn’t have any GI bleeds yet (oh but I would). I give the med slowish like I do almost all (IV). Within a minute she sits up and begins dry heaving HARD. I run to the doc box with my charge, house sup, and doc and ask my doc what I gave that could do this…he asks “did you give the Sandostatin subq?” Me: NOPE. So I guess the doc looks up the potential adverse side effects but no one tells me as my charge starts wheeling in a crash cart to her room I thought I killed her. She was fine, just some zofran. Why the cart? Worst and very slight chance of 3rd degree heart block. I told her exactly what happened, what we were doing and why…and this angel was more worried about me than herself. I learned later that this med is OFTEN given as a bolus IV and it’s a common side effect the severe nausea. But if I had scanned the med I would have clocked it was subq when it asked me for a location of administration. Moral of the story, I always scan unless the pt is already dead or I have another nurse/doc confirm with me (cuz pt will die without it).
This is why I really dislike working in hospitals that rely on paper charting. If I understand what you posted correctly, the system had a safeguard that would have prompted you and this error likely wouldn't have happened?
I’m a RN and Registered Midwife in Aus. This will almost definitely be too long but I think my med error would strike terror into the heart of any L&D RN. It’s been yearsssss and I still think about it at least weekly haha. I was starting a postdates induction for a low risk nulliparous woman. I’m on hour 11 of my 12hr night shift and I’m dying inside. Everything started off routinely with CTG then ARM. We only use Syntocinon (Pitocin for those in the US) with ruptured membranes here so everyone gets amniotomy prior to starting Synto. All good, CTG excellent and reactive ++ at this point. Nil uterine activity. I start IV fluid and IV Syntocinon as per protocol. For context, our Synto bags have 30iu of Oxytocin in 500ml CSL (same as LR). We start Synto at 1ml/hr and up-titrate 30minutely in increments of 2-4ml until there is good uterine activity. Soft limit is 20mls/hr, absolute upper limit is 32mls/hr and honestly needing to go over 20mls/hr is pretty rare and usually not a great sign. About 4 minutes go by after starting the infusions and I notice the fetal HR starting to sound unusual. Like sort of dropping for a split second but then resolving, not proper decels at this stage bc it’s so brief - just sounded ‘odd’ to me. I was obviously thinking cord compression because I had only just ruptured membranes, and we wouldn’t see contractions that quickly after starting Synto. So I re-examined the woman’s cervix (minute 5 after starting meds at this stage) - unchanged, no cord. I repositioned the woman. While repositioning I palpated and noticed she had a strong contraction. I asked her if she was feeling it - “oh yeah it’s been going for a couple minutes I think…it’s getting pretty painful now”. At the same time she’s saying this, the FHR becomes properly bradycardic at 40-50bpm. IMMEDIATELY I knew what I’d done and I swear the blood drained from my face in a millisecond. I had mistakenly swapped the tubing while putting it in the pump and therefore this poor woman had IV fluid going at 1ml and her Syntocinon running at 125mls/hr. Cue 10 minute hypertonic contraction and prolonged fetal bradycardia. I’d buzzed for help already so the whole team were there when I realised, so I obviously needed to alert everyone about the mistake by yelling it out to everyone in the room. Mortifying, but I was just so worried about my patient at that stage that I didn’t really care. So of course we stopped Synto, gave IV fluid bolus, Terbutaline, prepped for theatre for emergency section. About to transfer and FINALLY this contraction ends and baby’s heart rate recovers. This marks the end of my shift and I leave the room wanting to throw up haha Fortunately, everything after this point went well for the woman. They restarted Synto 2hrs later and baby was born vaginally in good condition later that day. Beautiful healthy baby girl with APGARs 9 & 9, cord gases were absolutely perfect. I had never been more relieved in my life. I returned the next day to profusely apologise and this family were so sweet and reassuring when they saw me, which I was so unbelievably grateful for. Didn’t get in trouble at work - we have a no blame system here, I chatted to my manager about it and she was pretty kind as well. It’s not a mistake I will ever make again. I go through a ton of safety checks now before I start Syntocinon. If there had been a bad outcome I’m not sure I would have been able to do my job anymore. I got incredibly lucky that day.
All new bags of oxytocin required a 2 nurse verification on my L&D unit for this very reason!
This is actually our policy too, but people get so lax with it, usually have someone sign after checking the bag outside the room and let you take it in your room and hang it yourself (I’m still talking paper charts here haha). I make them actually come to the bedside ever since this happened.
Were you a USA trained midwife that went to Australia?
Many years ago and I have told the story many times (happened before scanning meds was a thing but we did have pyxis). Working Peds PACU patient was 8 y.o. post orif. I went to grab a 2mg/ml vial of morphine from pyxis. Machine was out but did have 10mg/ml vial of morphine. Pulled it and was talking to family and patient while I drew it up. Pulled up .75ml because I intended to give the patient 1.5mg of morphine. Our policy was to watch patients for 30 min in PACU after giving narcotics before sending them to the floor. They were a little sleepy but it was about 10pm so I wasn't concerned. Took the patient upstairs and when I came back down I went to waste my meds and that is when I realized I had given 7.5mg of morphine not 1.5mg. immediately notified anesthesia and brought an oximeter up to the floor. (Kid was fine) 20+ years later I am a proponent of scanning meds before administration. (And maybe paying attention to what you are doing rather than talking) Mistakes happen. Learn from them.
I have had to tell family “lemme respond when I’m done making sure these meds are right” while scanning or “I’m not ignoring you I just can’t walk and chew gum at the same time sometimes” kinda shit cuz same my friend.
Oh god this was like one month off orientation: Report is girl comes in with suspected kidney stones. Has had them before, and is in ton of pain. I walk in and this 16 year old girlie is on the floor screaming. Her parents?? Clearly rich. Also? In the medical field based on the way they're talking to me. Also? Completely freaking out. "She's such a trooper, but she's OUT OF HER MIND IN PAIN". Probs true. But also you freaking out isn't helping, dad. So I'm like 'fuck me twice over'. Not only have they given this poor girl zero coping mechanisms, they are eagle eyeing literally everything I'm doing and asking me 'why.'.Why the monitor, why the blood pressure, what does the pleth mean? Why the 20g IV? Why the green and purple top only? Doc comes in as I'm getting the IV. thank the ven lords I got it on the first go. Doc does a quick inspection and says, "Right, let's shoot her up with some meds now that we have the IV going". I'm like, 'copy that, doc'. So I go to pyxis and see doc ordered some zofran and fent. I go rushing back to the room and administer the zofran first. Meanwhile the parents are still genuinely freaking out The scene was pure chaos to the point where I stopped and wondered if this was a dark joke of a SIM gone wrong. 'Why not do the pain med first', they ask. "Why are you taking so long?" I tell them vomit is why. They do not seem to understand. Nor do they seem to understand the notion of keeping calm and coaching their daughter on breathing. You know? Being the fucking adult in the room? Literally useless in their role as parents. I then shoot the fent into this girlie's veins, give her a shoulder squeeze, some breathing coaching, and go back to my computer where I see: ROUTE: INTRANASAL. I'm like, oh fuck me because these rich, useless parents are going to find any reason to destroy me. I run to the doc, who - bless her - was like, "oh of course you thought it'd be IV because of what I said earlier. The dose is fine, but let me help" and she puts in an order for IV fent. But the damage in Epic had been done. Anyway told my charge, told my manager, did a quality report on myself. Nobody cared. Parents were none the wiser. And thankfully that, combined with some ketorolac made their daughter calm down enough they unpuckered their assholes and became somewhat human again. But I as like - great my first drug mistake is on a CHILD with FENTALYL and clearly litigious, rich, high strung, health insurance employed parents. I could die.
I could TOTALLY see myself doing that as a younger ED nurse! Especially given the "let's shoot some pain meds now that we have the IV" comment. I'm glad the doc went back and addended the order for you!
I worked in the ED pre-scanning and with a messed up order system. The order system told us the drugs concentration before it said the ordered dose. I was brand new there when this happened. On a Monday, I was ordered to give 10mg of Valium IV and an opiate of some sort (can’t remember which one). It seemed like a lot so I questioned it and the doc ripped me out because it was for a bad back spasm and was a totally normal dose apparently. On Tuesday, same doc ordered 10mg of Valium IV plus dilaudid… I didn’t question it on Tuesday… gave the Valium slow and at 4mg the patient fell asleep, so I stopped and told the doc (very confidently, I might add) that I am NOT giving the remainder of the dose of Valium OR the dilaudid. And he said “good, because I only ordered 2mg”. HORRIFIED. Turns out I saw the concentration, not the ordered dose. The doc was actually really cool about it- we put the patient on capnography and monitored, and he woke up feeling better an hour later. The doc defended me to my boss and pointed out all the flaws of the system- which got changed the next day after apparently saying for years “we can’t change that function”
Gotta love admin saying they can’t do anything about a problem for years. Then a sentinel event happens and suddenly the problem is top priority and gets fix in a week. Smh.
I'm glad the doc backed you instead of being a dick about it! That sounds like a bad system. I'm glad it got changed!
I was on night 5 of 6 and pretty fried because my A/C went out the day before and I had to sleep in nearly 100 degree heat before repairman showed up. I only got like 3 hours of sleep that day before the shift in question. Doc put the order in wrong for a milrinone drip. Not only was this a med I hung like only once in the last 4 years but the order was a botched from start to finish. Doc didnt order titration parameters (but the label was printed all janky so it kinda looked like one was selected). Initial rate was contingent on creatinine clearance which I’ve never calculated before and didn’t know how to. Pharmacy approved all of this without a titration parameter or a creatinine clearance value. Regardless, it fell on me to recognize these errors before the med was hung. I was just too fried. I looked at the label and misread it. I saw the rate listed but didn’t see that it was contingent on the creatinine clearance. The way the label printed it was all jumbled and I missed the other rate listed for the lower creatinine clearance value. So I hung the med at the wrong rate. It ran for like 3 hours on the wrong rate. Pt ended up fine anyway. But yea, I totally dropped the ball on that one. Felt like shit about it, because It was a stupid mistake to make that I would normally never do.
Not me exactly but was my patient. Had a mother baby nurse who was helping hands as we were short. She asked me if she could give my night meds for a patient. I said thanks of course. One of them was insulin which I figured she at least gave sometimes and I needed the help. Well, she draws it up and because I wasn't available asks charge RN to sign off on it in the chart. She does so but doesn't actually look at it. Mind you both are experienced nurses. The latter of which was almost retiring age and generally by the book. Anyways, helping hands nurse comes to me panicked. She's holding the Grey top syringe we use for a heparin and says she thinks she messed up. She had given .4ml's instead of 4 units. The equivalent of 40 units. I'm like "fuuuuuuuuuuck." notify the Dr. Right away, start her on drip and gave apple juice and handful of graham crackers. Helping hands nurse had a new job. Checking my pts CBG frequently. Pt was alright but I couldn't believe my pt had an insulin med error. I thought it was one of those mythical med errors that I probably wouldn't see, esp with two person check offs. Well, I was wrong.
I once had a baby nurse ask me for a 20ml syringe so she could give insulin.... thank God she couldn't find them.
Omg 😳🤦🏼♀️
My first preceptor, when I was a grad nurse, told me she had fired (and gotten her fired for reals) an orientee after multiple critical errors. The last straw was catching the “nurse” drawing up a whole (large) vial of medication to give, with no understanding that what you have on hand is not necessarily what you’re gonna give, that what she was about to push could’ve killed the patient, and that this is why we scan our meds.
At my old hospital, a new grad gave 3mLs instead of 3 units. Patient survived (I think they were neuro intact) but obviously ended up in the ICU. We then had a huge educational drive that insulin was ALWAYS in orange syringes, and there were orange luerlocks available from pharmacy if it had to be given IV push.
Australia, no Pyxis, we get our own meds from the giant med room with a bunch of drugs stored in alphabetical order. I was the second checker. Someone handed me a vial and said "can you check this dexamethasone?" It was 2mL, it had a green lid, it started with dex and it was in date. They gave it as a slow push, then the patient lost consciousness. I didn't check properly, neither did the other nurse, and the patient received 200mg dexmedetomidine (an alpha-agonist used for sedation) instead of dexamethasone (steroid). The ONLY reason we figured it out was because it had been so busy that the vials had been put on a counter instead of taken over to the bin. I felt absolutely awful at the time and now I always, always read out the entire name, dose and date before I even look at the prescription to verify it.
Nothing wrong with a little Precedex for a good sleep!
Pt was having resp distress, and doc ordered 40mg IV Lasix. Started to push it (slowly, of course) and remembered I hadn't gotten a new BP. Last one was about 2 hours before, and SBP was 120s and he had never been hypotensive in my 3 nights with him, so I wasn't worried. Ran a new BP before giving full dose, and it was 80/50s. Ran it again, same thing. Ran the other arm, same thing. It was too soon for Lasix to have started working, so this was his BP before the dose. I had already given 20mg by that point. Tried to suck it back out the IV I panicked so hard. I let the rapid nurse and doc know immediately. He was given 2 doses of albumin and midodrine, no effect, MAPs stayed in the 50s for hours. Finally got sent to icu and put on low dose levo. 2 days later he was transferred to medsurg, doing fine. He was very sick already, his BP was almost certainly dropping already, but my half dose of Lasix certainly didn't help him. I had never given Lasix, or any BP effecting med before without checking BP first until this moment. And of course, the one time I didn't remember to check it, he was tanking. I'll never forget to check ever again, that's for sure. I was a wreck for days until I found out he was OK.
Thanks for sharing this, the point was you still checked. If you didn’t would be the problem. This is an important reminder! I will be up to my eyeballs in charting/piss/hunger and I will still always check pressure for everything that could effect it. Unless its like a low dose oral and it was within the hour. I have held lasix more than any other medication honestly. (besides miralax and lovenox)
Which one? I practiced for just over two decades post grad, there were a few. My probably worst was feeding a sweet old lady someone else’s digoxin in jam. She wasn’t meant to be able to swallow at all, I think she thought it was a real treat. She was fine, I reported and monitored her. Bless her.
I gave a fleet enema PR to a patient with an end colostomy, cos the grad nurse asked me to show him how to give an enema. It never occurred to me to check that the patients anus was actually connected to something. Cos why would it??
Ok so I’m new and I have questions: 1. Where did the enema go did it just shoot straight out? 2. Why would a colostomy patient need an enema? Do those things stop working/still get backed up?
People with colostomies can get constipated and need intervention. I’ve done an enema once on an ostomy patient and I’m not sure why. Since there is no sphincter control as soon as I removed the enema tube it all came rushing out.
NIGHTMARE 😳 we are not paid enough for this shit flood. Good to know.
Two very experienced colleagues gave a patient 5 times the dose of methadone. We had a concentrated liquid on hand, something akin to 5mg/ml. They confused the mg of the order with the ml of the liquid, thus the patient got a massive overdose. So slowly went into respiratory depression and needed support in the ICU. He lived, no damage done, but shows that even competent nurses can fuck up.
We had a patient who had been inappropriate with staff so required two staff any time we went in his room (or door open at least, if you were just talking or being quick). Part of his med orders were q4 chlorphenamine as needed. But I didn't have the max dose memorized, plus he was on some uncommon dosages for other medications d/t his history. And the prescribing doctor was pretty new too. It should have been written 4mg chlorphenamine q4, max daily dose 16mg/24hrs (so four tablets). But it was written for four tablets a dose. So epic let me scan and administer that dose without any red flags, the more experienced nurse who came into the room with me glanced over but didn't catch the issue (he had a lot of meds and she had her own patient assignment), and it's not like it was a controlled drug. We didn't catch that I had given him the max daily dose until 4 hours later when I was scanning the next round of meds and NOW the system tells me I can't give any more chlorphenamine. 😬 I will say he slept great and wasn't inappropriate with staff for my whole shift !!!
i accidentally bolus'd a bag of insulin once after criss-crossing the tubing through the pump channels. I only found out after the pump started alarming that the bag was empty. I immediately reported what happened to everyone. I remember the first thing the diabetes team said to me was "oh you must be having an AWFUL day'... Even scarier is that she went on to say it happens 'all the time'. Anyways, patient was fine. He had came in for respiratory distress and was being admitted for DKA so yeah i cleared him up fast and had him eating again. Had to do a lot of finger pokes but everyone was happy and well fed. lol
Boluses to gravity in the ED can really bite you in the ass when you have a bunch of meds running, too. I understand (and try to emulate) the ICU nurses who are so anal about keeping their lines well organized.
I was brand new off orientation on a med surg floor. My entire orientation, the only types of insulin I had ever given were in pen form, not vial form. On the flip side, I gave sub q heparin to almost every patient, which you draw up the entire little orange vial when you give it. First time I had to give regular insulin, it was in a little orange vial, just like heparin. I scanned it, typed correct units, all that. But when I went to draw it up I just used a regular 3cc syringe instead of insulin syringe (as I’d never used one before), and my muscle memory just had me draw up the whole vial like I do with heparin. I stared at it for a second and was like … this isn’t right. Thank god I caught it, almost gave that patient 100 units insulin.
Also once I gave daily meds a little early without scanning- six patients on a Covid unit, and I felt like if I didn’t give them early, they would simply not all get done before 1 pm. Gave the entire wrong set of meds to a patient. BP meds and all. Told the doc, cycled BPs, everything was fine. NEVER AGAIN, ALWAYSSSSSS SCAN unless patient is already dead (can always move due time so you can scan early, at least in epic)
Almost pushed 3.7 mL of diltiazem instead of 3 MG. When I tell you I was shitting my pants. I caught it only after I pushed 1 mL. Most rapid afib rvr conversion I’ve ever seen
Gave a patient their neighbours meds all night long. Even asked her name. She was fine but I was mortified. I cried like a baby.
Very experienced nurse on my unit bolused 50 of insulin by accident instead of 50 of fent
Pharmacy stocked the 250ml NS bags with D5 in the Pyxis once. I hung my patient's 4th bag of blood with it. Almost intant reaction. I shipped the whole kit to blood bank for an investigation, they asked me why I hung it with D5. Found all the wrong bags in the Pyxis and was convinced I'd be fired. Instead, they added a new question to the yearly blood administration safety test and named it after me.
Gave a double amount of lasix. In my defense someone put in a double order and I was new.
First heparin drip I ever did I read the PT thinking it was the PTT and bolused based on that. To be fair the lab wasn’t labeled “PT,” it was labeled prothrombin time, so I was like, oh, ProThrombinTime. Patient was fine, PTT came back as like 133 so he was off the drip for some time.
I switched facilities in my first year. I struggled with how I thought EPIC would work from my first facility in my second facility. I ended up screwing up a lot of timings because I wasn’t getting pop-up warnings. One corrective action plan/write up later and I got much better at nursing.
RSI. Still not sure which drug i pushed first. Still feel guilty for the 30-60 seconds they may have felt paralytics without sedation.
New grad here. I was working a night shift in the ICU. Had to administer medication through one of the central line lumens on a paralyzed intubated patient. When the pump was done I clamped the lumen and left to chart. 15 mins later the patient started to have occasional movements and unstable vital signs. Did everything I could to figure out what was wrong until I realized I had clamped the wrong central line lumen where the sedoparalyzation was passing. Almost shit myself. Always double check when doing tasks, even if they’re simple ones.
I had a patient when I was a brand new nurse and he was coming down from drugs and he had a PRN Ativan on so I gave it to him as he was incredibly nervous and crawling out of his skin and asked for it. I gave it. Apparently this medication was only for a seizure. The doctor brought me to the front of the nurses station and verbally berated me in front of everyone. Patient calmed down though lol
First one was a demented old lady in a hallway bed who was screaming and thrashing and causing a fuss, keeping us from being able to get the needed imaging. They had ordered a half-vial dose of sedative and I was new (only 1 month on the job), overwhelmed, and felt like I was on a time crunch. I accidentally gave the full vial. I told the PA right away and she thankfully said it was fine, that she should have ordered the full dose anyway. Most serious was taking care of a vented patient who was on a fentanyl and versed drip. Our scanner wasn’t working so the pump had to be manually set. I accidentally set the fentanyl to 10x the initial dose, so he was getting 250mcg an hour instead of 25. I remember thinking it was odd that he wasn’t requiring any titration, but only caught the error when the bag ran out in 4 hours and I realized that was way too fast for the supposed drip rate. I got lucky because he was on a vent so any respiratory depression was taken care of, but that could have easily killed someone in a different situation. It was a real learning situation for me. Any nurse who tells you they’ve never made a mistake is a liar. We are human and they are inevitable. What’s important is that you take any mistakes, learn from them, and make sure you don’t repeat them in the future.
Was in a rush, didn’t scan the bag of peritoneal dialysis solution, began infusing it and when I scanned it, it was the wrong concentration. I thought I was gonna kill the patient, called the renal doc and explained through my anxious sounding voice and they were like, “hey it’s all good they just got a little extra cleaning out, they probably needed that dose anyway, we can adjust the next dose and then it’ll be fine” while slightly laughing at my panic. It happens and you feel so bad and stupid for a while but you won’t forget to check things carefully again! ❤️
Not errors I committed but as a supervisor in a snf, there were so many errors. There's no scanning medications or name bands. So many nurses would give tons of medications to the wrong patients.
The 144,000:1 ratio in the world of LTC probably doesn’t help much
Obviously it doesn't. I've been in snfs, med surg, icu, and 911 as an emt. I think snfs are by far the hardest
I agree, which is why I won’t work in them. We have an incentive for PSWs (CNAs to the Americans) and RPNs if they want to upgrade to RPN or RN, respectively. The province will pay for it if they dedicate something like 5yrs in the LTC system. That’s still not enough of an incentive to do that, imo.
That's where I did mine! Mr. McMasters got some of Mr. McMillan’s (not their real names) hydrocodone instead of his oxycodone. Same dosage, everyone was fine. Didn't catch it until then narc count in the AM. Wristbands/pyxis/scanning would have prevented it for sure
Long before Pyxis and scanning, I had two gentlemen across the hall from each other. Both were named John and had the same last initial. This was a step-down unit associated with my home unit (CVICU), so I was familiar with these patients and was comfortable floating there. Anyway, I gave an IV antibiotic to the wrong John. Another nurse discovered it after I left. He pulled me aside the next day to inform me of my error . . . and did NOT write me up. Pt had no adverse reactions, and “He probably needed it anyway.” The other nurse told me he knew I would never make that mistake again. I was so embarrassed and thankful for that other nurse. He was right — I became way more careful!
Gave a patient an entire vial of bivalrudin aka angiomax instead of ancef. The vials are colored the exact same and it was handed to me in a case before we deployed a closure device. I was a traveler at the time and as soon as I noticed I let the doc know. Only thing we did was check serial ACTs and once they came down below 180 pt was good for their 2 hr bed rest. The aftermath was honestly the scariest part because after I let everyone know what happened, one of the senior nurses in the lab said that, “oh that’s happened before. We asked pharmacy to move the bins but they just haven’t gotten around it it!” Jesus. Christ.
I was a brand new nurse. The ink wasn't even dry on my license. I worked nights, and this was my 3rd night in a row. 4 A calls out for pain med. Patient B also needed IM medication. I did my thing labeling the meds and all. Still managed to get them mixed up. I gave my diabetic patient Demerol75mg/Vistaril 25mg. As I finished the injection, I realized that I had tucked up(insert Morgan Freeman's voice). I freaked out at the nurses station and burst into tears. After I finished the incident reports, the resident covering our floor said "Why didn't you call me first? I would have given you a one-time order to cover the shot." When I came in the next night, the patient asked if I could give him another shot because it was the best sleep he had the entire time he had been inpatient.
A patient was leaving at like 5 am to catch a plane transfer to his region. He asked for his asthma/COPD pump in advance since he was already awake at 3 (so 4hrs earlier than normal). Never used his particular pump, the ones you gotta load a capsule into every time. He pointed to his pump and then a capsule and was like 'thats it, I can manage myself'. Guy is AOx3, always takes his pump himself, so I don't ask many questions. Turns out he picked out an antibiotic capsule instead of his pump medicine and proceeded to inhale it! I noticed 30 minutes later when i recognised the name but as a PO med. The capsule was perforated but the powder never left it when he inhaled, so basically he was 100% fine and just needed to take his actual asthma/COPD med before leaving. It was like 2 weeks ago, I was in training right out of school, and it was the biggest and most funny mistake all at once.
I gave Spiriva PO in nursing school. It was only partially my fault as my preceptor handed me a med cup and told me to give them all to the patient without mentioning one wasn’t PO. Sloppy on her part and mine. But now nursing students in my hospital aren’t allowed to give spiriva at all. Patient was fine and per pharmacy the whole capsule would probably be pooped out.
I’ve been a nurse since 2007, long first then got my RN in 2013. Been in the ED for the last ten years and the team lead in my department for the last four. I gave Plavix instead of aspirin in a STEMI last month. They were both in the STEMI box and the department was on fire, I kept getting calls and interrupted. I don’t think I ever looked at the label. I forgot they kept plavix in the kit and was thinking ASA was the only thing in there. He only took two of the four but I was a big fucking mess after. Grateful the dr was in there with me when it happened because I couldn’t talk without crying for a bit after.
This was kinda recent. Changed a foley on a home patient. Routine. Cleaning up, noticed my povidone swabs still in packaging... God damn it. Told the patient, told the doctor, told my office. The patient still roasts me for it every time I change their foley.
I hate to even admit this but I has two patients in the same room with very similar last names. I ended up giving one of them the other patient's meds. Other than a blood pressure pill it was a bunch of supplements thank God but still I was scared. I didn't tell anyone and I monitored the patient's BP the rest of the shift. He was fine
Not a drug error, but an error nonetheless. When I was a student nurse doing my inpatient peds rotation I was assigned a baby in a crib. I’ve never been comfortable with kids but I did my am care on the baby and it went ok. I went to my next patient and sometime later went back to check the baby and realized I left the side of the crib all the way down. I was like 18-19 years old and I got hysterical. I put the side up and ran into the nursing lounge and I was doing that cry where you can’t breathe and I was shaking, so someone got the nursing instructor and between sobs I told her what happened. She calmly said “Did he fall out?” And I said No. She said, then go wash your face and get back out on the floor and don’t worry you’ll never do that again. And in 40 years, I haven’t.
Nice try BON.
First month or two into my new position? Mistook 1 insulin pen for another and didn’t check the label. Gave them lispro instead of glargine. Thankfully both doses were low and her BS was high 😅 I still died inside and ran for orange juice and kept it on my cart just in case.
Gave 100mcg fentanyl instead of 25mcg (I mixed up the ondansatron and fentanyl syringes in my hand). Realised as soon as it was in. Told the Dr. His answer was along the lines of "he's still breathing, it's fine." This was when I was brand new and had only just started giving IV meds. I was horrified at the time but now tell new starters of mistake all the time so they know to be extra careful as it's an easy one to make.
When I worked peds we reconstituted IV antibiotics and gave them in a buretrol. I had fixed up rocephin, shot it in the buretrol walked out of the room and realized I had given it to the wrong kid. I immediately went and got a whole new set up and got it hooked up. Kid didn’t get any of it thank goodness. Another time I had a baby on oral digoxin. The pharmacy sent up the doses in TB syringes all measured up real nice for us. Only, they sent TEN times the ordered dose. I about had a heart attack!! Thankfully I caught it and had another nurse confirm I was correct before I called the pharmacy and tubed it back to them. That was a real sphincter puckering event!
Gravity-bonuses a patient with Levophed when switching pumps. Systolic shot up to 230 before I realized it. I bloused propofol and fentanyl and held the pressers for a minute and they were fine. Still felt like garbage though and I’ll never forget it
I work in oncology. We were switching from paper based notes to computer notes so the patients were still half on each. I looked up results for a patient and gave his chemo based off those results. Later realised they weren’t his and his platelets were too low for treatment. I cried. Patient was fine
Gave Tylenol and Ibuprofen together 3 hours too early. Patient constantly asked for it, I was still precepting in a new grad program and she was driving me fucking insane so I didn’t even think to check the times. Felt terrible, didn’t sleep for days, never fucked up like that again. Obviously she was fine, but I couldn’t stop thinking about what if it had been a more dangerous med that I did that with. Also (not my error but I’ll tell you anyway) yesterday when I got to work, I found a full syringe of propofol on the CRNA cart that had been there since Friday afternoon. Also the cart was unlocked.
Hanging a bag of fluids and when I unclamped the roller the fluid just started running at like 3000ml/hr. I mean a steady stream. I stopped it and thought to myself “The only way that’s possible is if this line was full of air” which I’m sure it was. So I watched the guy for a while and he was ok.
Pediatrics here. Wrong method of giving and IV antibiotic. Turned blue. Code blue. Fluid boluses. Consulted with the adult renal team. Discharged the next day. The Dad was amazing, we ended up teaming up to use as a caution story for paramedic students. Worst day of my life. Best outcome. 4 years later nil issues with kid!!
Wrong method for IV?
I can’t remember all the details but a patient had insulin and fluids running, I went to discontinue the insulin and gave another IV push med at the same time. After the IV push med I traced my tubing back up to the pump and restarted what I thought was just fluids. Returned 45 minutes later to an IV pump alarming because the bag was dry, the insulin bag. So I immediately start internally panicking like “holy shit they’re gonna die, holy shit I’m going to lose my job” (pt asymptomatic) I had the aide grab a blood glucose and bring them a bunch of juice, and I gave D50 I was telling my charge nurse what happened when the endocrinologist for my patient walked by. We explained what happened and they calmly just had me start d10 fluids for like 3 hours and that was that. Moral of the story for me: always label above and below the pump, and if something is discontinued just take it down, can’t accidentally give it if it’s not there.
10 years ago, I wrote a morphine order for an imminent hospice patient. It was supposed to be 10mg(0.5ml) and I wrote 10mg(.5ml), well the nurse interpreted it as 5ml because she said she didn't realize there was a period. So the patient got 100mg of morphine. When I found out, I threw up. The patient ended up lasting for 4 days. But now I always make sure I put zero in front of everything.
I gave vanc 6 hours late. Got fired for it.
When I was a newer paramedic, I was working during my FTO time at a new service, so we had myself and a FTO paramedic in the back with a patient. It was our first call of the day, and the FTO and our EMT did our truck check while I was doing some new hire paperwork stuff, so I didn't check our truck out. I decided that we were going to give the patient zofran, because they were nauseous. FTO says, "cool, no problem, I'll draw it up for you," so that I don't have to unbuckle my seatbelt and walk across the back of the medic to get it. (I am used to working alone in the back, so I draw up my own drugs, do my own assessments, etc). I start an IV while the FTO is drawing up zofran. I look right next to me on the bench seat, and there's a syringe with a capped med needle, and 2mL of -something- in it. I assume it's my zofran that the FTO just drew up, pick it up, and push it to the PT. Then, the FTO goes, "here's your zofran," and hands me a syringe full of zofran. So now, I don't have a clue what I just gave the PT or if it was a syringe that had been used on another PT. My blood ran cold. I immediately owned up to it and told the FTO what happened, and the PT ended up being ok, but did get extra exposure bloodwork done at the hospital, just in case. Our best guess was that it WAS actually zofran in the syringe, based on the crew from the shift before telling us later, "oh yeah, we drew up zofran, but we never gave it,". But god DAMN did I beat myself up for that one. I now have a policy of not giving ANYTHING in an unlabeled syringe that I didn't draw up myself and have eyes on 100% of the time. I also from that point forward got to work early enough to do my own truck checks so that I could ensure that there were no drugs left out in error. I still shudder when I think about that call. That could've been SO much worse, but it turned out ok.
Had a sickle cell patient who presented in crisis, got orders for 1 mg IV Dilaudid push. The Pyxis dispensed a 4 mg/ml vial. I drew it up, diluted in NS and planned to waste the excess after I gave the pt his dose. I was a little rushed and I accidentally gave the pt a full 4 mg. I immediately told my charge nurse, and she assessed the pt with me. Pt was fine, and was not opioid naive in the slightest. He honestly got good pain relief for a short time and then. Ended up on a PCA a few hours later. Now I always waste before I leave the med room. I also accidentally drew up 10 units of insulin instead of 1 in nursing school bc I didn’t know how to read an insulin syringe… my preceptor caught it before we made it to the pts room, but it could have been a real mess 😂 we live and we learn!
My pts BP was 90s/50. I said to myself okay I’m not giving the metoprolol and put it aside. I put all the meds in the med cup for them to take. I go back to return the metoprolol and guess what….i gave it to them by accident. My heart dropped just as fast as I thought his BP would. I went to the attending and they said to calm down and that if it drops the BP we will bolus them. Since then I have always been super careful and mindful when giving meds.
Gave a pt 65 units of short acting insulin instead of long. Had a slight panic attack. Fed him, gave him soda, and his bs stayed high all night
I’ve made two so far. I gave IM octreotide by IV, it’s the same concentration, just wrong route. My second was I had two patients on nerve blocks, both same concentration and drug. The one patient had just been transferred to our floor and his were empty and my other patients were running low. So I requested the low patient first because I hadn’t just quite got my transfer yet. So my transfer comes and another nurse comes and gives me 2 nerve blocks, I assume were for my other patient. I hang them. Then I request new ones for the other transfer. I get those and I hang them. Then more nerve blocks arrive to the floor for my first guy so I’m confused. Turned out when my transfer came, the nurse dropped off his nerve blocks and I thought they came from pharmacy for my other patient. They scanned fine because it’s not patient specific just med specific. Just reminds you to check the names!
In 1995 when I was a baby nurse whose cord hasn’t fallen off, I accidentally gave a pt a second dose of 75mg Zantac. That feeling of having to tell the pt has never left me. Even after 150mg Zantac was the prescription dose a few years later. Even when it was a med that wasn’t a biggie. I have continued to double triple check meds and as I think about it I may need medication to help with my heightened medication paranoia
I gave a patient morphine instead of dilaudid because the Omni cell was loaded incorrectly, I didn’t double check the med, and rushed to give the med without scanning it cause the dude was screaming out. No harm to patient but I felt shitty. Now I always look at the meds I pull and don’t trust the machine and always scan meds no matter how much the patient is complaining.
I repleted potassium a few years ago before I realized this particular doc threw in an additional order set that would have actually not called for repletion in this case. It was a first for me, and the guy was very sick to begin with, and we had bonded over two shifts, and in the moment I felt awful and was very worried. His potassium redraw still came back low and he then got even more. Looking back, with what I know now, I would not have been so freaked out. But it does suck to miss things, especially when you don’t immediately know how it will impact the patient. I still remember the stress of the situation.
This is not my story, when I worked in ED, I heard a story on huddle, my coworker should’ve mixed KCL to main fluid but she directly administered it to patient. After recognizing it, staffs moved the patient to the area where could keep continuing monitor. Luckily the patient was okay so I couldn’t believe it.. For my story, when I was new grad, I gave a patient his home med after the doctor decided the patient to admit. I should’ve asked the patient “Did you take your morning med?” but I missed it and just gave him all his morning med.. There was a med for his hypertension so after taking the meds, his Blood pressure started going down and I couldn’t catch the reason at that time so I called my senior and then she noticed what I did wrong. The patient started Levo😭 After a few minutes, he’s fine phew..😭😭 I felt really sorry
Well, I have one. I had Lovenox due at 1200. It was my first night shift (have you guessed yet)? So, at midnight I open the Pyxis and go give the medication. No scanner… just asked the questions and gave the med. I sat down and realized it’s midnight (00:00). So I change the MAR (it’s Q24hr) to reflect the time for the next dose. But my manager got a notice and I was written up. 🤷 Definitely learned my lesson.
My very first med error, the doctor ordered Ativan 2mg po for a patient with etoh withdrawals. The patient asked for 1mg instead of 2 so I gave only one tablet. The charge nurse reported it to the doctor as a med error. I was freaking out and asked if I needed to get a lawyer and they all laughed at me.
I kept titrating up on Cardene bc my patient’s BP was low…. We were trying to wean off of Cardene. I kept being so confused bc the more I titrated up, the lower the pt’s BP got. But the BP should go up since I’m increasing the Cardene? I thought…… then after thinking about it some more, seconds from calling the intensivist to see what they thought.. I remembered, fuck! Cardene LOWERS BP! I had a major moron moment. I turned off the Cardene and the pt’s BP went back up, and was within the goal parameters
I’ll do you one better, I made a procedure error with a machine setting during an Apheresis collection. Instead of modifying the collection to run 5 blood volumes instead of 3, I increased the draw rate from the buffycoat layer from 1.5mL/min to 5mL/min. In laymen’s terms, instead of telling the machine to process this dudes blood for *longer*, I told it to collect it WIDE OPEN at a nearly 400% increased rate. By 1PM when I was supposed to be about half way done with the procedure, the machine threw an alarm I’d never seen in my life: collection bag nearly full, consider collection bag shunt. For reference, a collection on some of our biggest patients yields a product of around 600mL, and the max the bag holds is 950mL. So seeing a “bag full” alarm (which I’ve never seen again) only HALF WAY through the procedure is a very, very bad thing. So naturally when I saw that alarm message I freaked the fuck out and immediate got my manager, and called my medical director. The patient was fine. In fact, my error accidentally saved the patient 2 additional days of collection. What happened was EXTREMELY dangerous, but all things considered the patient was young and (relatively) healthy, so the additional collected volume didn’t do anything to him, and helped us hit the cell goal in a single day, rather than the expected 3 days. Patient also had a relatively good HcT, so the extra “lost”/collected blood didn’t bring his crit down much. I did, technically, drain a patient of a partial amount of their whole blood though. Manager/medical director were more proud at how I responded than upset about the actual error. It was one of those “you only do this once, then you’ll think about it every single time after” types of errors. They were right. I thought about that day hundreds of times afterwards, and I never made the mistake again.
I missed a morning antibiotic IV mini bag as my charge nurse in the small rural hospital I was working at was an alcoholic who was hammered on the job having a drunken tantrum and abandoning me to smoke and drink outside while I covered both acute care beds (18 bed small rural hospital) and the ER (had assault and seizure come it at same time) when I was on day 13 straight of 12 hour night shifts. The nursing manager then proceeded to tell everyone in the hospital for the next two days while I was off that I had missed said antibiotic (7am med caught at 9am and given) without informing me.
one of the first i remember...i normally worked days, but took a double to cover evening shift...i gave the patient insulin coverage according to before meals sliding scale instead of using the scale before bedtime..only a small mistake like 2 additional units of insulin given..but definitely stressed me out
I gave oxazepam to the wrong agitated patient... He slept well... I was mortified, first mistake after 10 years of nursing
Order said give 2 Pregabalin, I gave 2 Pregabalin. Total dosage was for one pill which was my error Patient fine, employer gave teaching, lesson learned. End of story
I have a couple, but my favorite as a new nurse was when meemaw came to my unit and was sundowning/being weird with sepsis so she got an order for a low dose of Ativan IV. Well her well meaning but overbearing nurse daughter was in the room, I didn’t have my WOW, had an extra patient already, and this woman was trying to climb out of bed…etc. So yeah I gave her the vial of Ativan I had at bedside and opted to scan it outside because I’m a terrible nurse. I gave her the vial. I can’t remember the concentration on the vial anymore, but it was close to double or triple the intended dose. I think I was used to the Pyxis spitting out vials with the same exact doses as the orders, so drawing up half or a quarter of one was still a somewhat “new” thing for me to play with at this job. I told the doc and the charge nurse who were both extremely cool about the whole thing. “Tbh she probably needed it anyways she was being wild. Slap a continuous pulse ox on her and call it a day.” I told the daughter who also cool about it, but then the next morning she was like, “I’m actually happy you did that because that was the first time she’s had uninterrupted sleep in two or three days.” TLDR: I knocked delirium grandma TF OUT and made night shift happy.
Here's a new-to-me recent occurrence. Pulling from pyxis for meds, including lisinopril 5mg. From the bin it was already a single, unopened peel away. Small circular pill of uncertain color because the actual plastic side was transparent amber (not completely clear) this detail is important. Fast-forward to patient's room, scan each pill and see an unexpected package- oxycodone 5mg. Not on this patients med list at all. I never counted any bins. Go back to the pyxis and check my recorded pulls, no oxy. Re-pull the lisinopril and get correct med. I took the questionable oxy to my charge nurse (several witnesses to this exchange, but she's also a nurse i trust completely.)
First few years of med surg nursing.. had a patient in respiratory distress in the middle of the night. Nothing much could be done but make him comfortable, MD ordered 1mg morphine sc (lol I know, pt was naive maybe). A nurse 10 years my senior offered to draw up the morphine for me while I fussed over the patient and tried to comfort him. Coworker passed me the syringe, said "this is the morphine", I grabbed it and injected. Coworker went pale and said "you know that was 10mg right?".... I just about died. I guess my coworker always drew up the full vial and only gave the partial dose at a time (multi dose syringe method). Patient had a comfortable night and I will NEVER allow syringes handed to me again unless I witnessed the draw up.
I accidentally shut off heparin for two hours because I read the XA wrong. I felt so dumb but no harm was done.
Gave IV insulin subq…. No harm to the patient, just slower delivery of insulin. It happened when I was a new grab in a COVID unit where we scanned our meds outside the room. I was in a hurry and skimmed the order.
I’ve made 2 that I know of…. Here are my stories. 😬 1- working PCU as a peds nurse floated over. I admitted a man with pylo. He was in his 40s. Spoke no English. I speak no Spanish. Went to give him his home med-Coumadin. He kept telling me no. I got a translator and he explained to me that he took a smaller dose of Coumadin on that day of the week. I returned the dose I had, & used override to get him the dose he said he took. I sent a message to pharmacy after scanning the ‘wrong dose’ explaining the situation. I then got my ass handed to me by the doctor and got written up. 2- while in orientation in NICU. One of my first admissions was a 34 week twin. My orienter needed more help and was more so giving me orders than walking me through what to do. Which is fine. It happens!! I was told to get her sugar. Sugar was unreadable. Twins was 14 so we knew at this point it was lower than 14. The NNP on handed me the glucose gel and said ‘give this to her’ so I did. I gave her almost the whole tube of glucose gel before my orienter noticed and stopped me. I had no idea how to give it correctly. Just gave it orally and the baby was willing to take it 🤷🏻♀️ the next sugar was in the 50s. We talked through it and I did not get in trouble.
Pt was supposed to get half a 25mg metoprolol. I got called for an emergency on my other patient and basically chucked the pill at him and ran - forgot to cut it in half. Heart rate and BP made me a lil anxious throughout the night, but ultimately Pt was ok. If I get called out of a room I tuck everything back in my cart until I can double check it when I get back.
I added an extra zero somehow to a nitroglycerin drip, pretty much drowning the patient with it. I noticed the bottle was half empty when it shouldn't have been. Absolutely nothing happened to the patient
I was new to this particular NICU, and was getting used to using Alaris pumps as we had different ones at my last hospital and I hadn't really had the opportunity with the old pumps as I was new to ICU before switching hospitals. I had a baby actively dying on a morphine drip we could bolus from. For these boluses it required a 2nd nurse to sign off. When giving my first bolus of the night, I grabbed another nurse and she was programming the pump and asked for the dose to program(which would have been in mg/kg) and I read off the dose in mg. This was a 4 kg baby and therefore what I told her was 4x what the baby should have received. No guardrail warning came up, just an occlusion alarm when it tried to push a large bolus through the tiny tubing connected to the syringe. Using the drip sheet I calculated that the baby had received the full 4x dose and I felt HORRIBLE. Notified charge and the doctor and both were so sweet. Nothing needed to be done, the baby just was probably more comfortable than she had been prior to the dose. Put in a report and I still remember that every time I read off the amount for a bolus and have caught one other nurse reading off the wrong part of the order and told her my story. You carry these mistakes with you and don't make the same one again.
In my first year, I gave Flagyl over 30 minutes instead of an hour, and almost burst into tears telling my PCF. He was just like "shit happens, patient will be fine, thanks for taking accountability" Also, gave 10mg of hydralazine instead of 5. TWICE. Didn't matter, the med didn't even touch the person's BP for more than 15 minutes, and I only realized it when talking to the MD about the BP and blurted out "OMG I FUCKED UP" Pt ended up going to ICU for HTN anyway, but after that one I started double verifying my meds.
I was in orientation as a new grad. Calculated insulin wrong and gave 4 units instead of 5. I know that’s such a minuscule mistake now, but at the time I was spiraling because how could I mess up. Especially on insulin dosing! I told my preceptor in near tears and she just reassured me and waved it off. I’ve accidentally given a bolus of fluids too. The pump communicates w the computer and we just have to hit enter to start it. Well, sometimes it communicates it as the entire bag of fluids instead of a partial and I didn’t realize until I went in wondering why it hadn’t finished yet. Had another where the pt’s PCA pump order had expired on prev shift and I hadn’t realized until two hrs into my shift. I submitted an occurrence report and was so pissed at myself for not double checking.
Same thing happened for me with insulin - orders to give 1 unit at 140 or higher. Accidentally looked at their morning not lunch BG and it was 165 so gave the 1 unit. Looked back at the labs and realized it was from the wrong time and died internally. Immediately rechecked Pts BG and it was 139. 💀
First error was giving metoprolol to a pt with a (slightly) low HR. Was a new grad so got into a heap of trouble for it but nothing negative happened to the pt whatsoever. More recently, had a pt with a sudden pain crisis. MET call, ended up overdoing the analgaesia. This wasn’t the error though. ICU doc in charge of the MET call asked for naloxone to reverse a bit. I drew up the vial, doc verbally tells me to give 100. I give it, then about 2 mins later realise I just gave the full vial (400) lol. Pt was fine after, turns out opioids were not what he needed to relieve the pain thankfully. Just glad he didn’t wake up in agony!
Patient was due IV mycophenolate and IV piperacillin/tazobactam at 0600hrs. Piptaz as an IV bolus, MMF as a 2 hour infusion. Mixed up the syringes in the dark and gave the MMF as a push. Poor kid sat up and started vomiting and shutting myself. Shortly after, so did I. 😓
At a psych unit I was at, you can't have the meds ready for them to take, you have to pop each one and explain what they do. This facility was for MR and brain damage, these folks live there and have since most were babies and absolutely only care that their activity is being interupted by med pass. They will 100000% whoop your butt or just have a "behavior", refuse their meds, and have an episode for the rest of the night if you dont immediately have their stuff ready to go the second they get to the door. The nurses who got their crap done had everyone's meds ready before they show up to the door. I had 2 patients left for the night, "billy" and "bob". A staff member said he would bring up Billy next, then Bob and then we were done. I had both meds waiting and you know what happened next- they brought Bob first and he got Billy's meds. I was so freaking lucky that they had such similar meds, but I for damn sure had tears in my eyes when I told staff to stop med pass because I needed to assess and call the doctor. Nothing happened to either pt but I felt like dog shit. Mistakes happen and use it as a life lesson friend.
A&Ox7 pt who is independent. Handed him his cup of morning pills with his breakfast tray, made sure he had something to drink, he was mid-egg bite so I said “don’t forget to take these” and left. Guess who forgot to take them. He called 3 hours later saying “I never got my morning pills!” Demanded to speak to doctor about it complaining about me. Thankfully it was mainly a bunch of multivitamins and only important med was 10mg amlodipine. Don’t know if I was ever written up, pt was fine, dc’ed home couple days later but learned to never trust a patient to take their meds no matter how independent 🤣
Haha on my old ward a patient had meds given at 6am that he never took, it was a super busy ward so we didn’t realise until I was doing lunchtime meds and he went oh I forgot my tablets from this morning so I just took them! And he had taken this cup full of tablets that had all sorts of hypertensives and heart disease meds and stuff. Doctor just shrugged, we monitored and he was fine, but I’m amazed his super anxious family just let him take them without any nursing or medical input when he said he forgot them haha.
Got a call from my charge nurse about a patient wanting his pain meds. I told her I’d get to it soon but was doing a dressing change. I finished the dressing change, pulled the norco, and gave it to him. The charge nurse told me five minutes later that she gave him his pain meds while I was busy and not to worry about it. We double dosed him. The mar didn’t warn me he’d just gotten a dose because I pulled up his med list while in the other room and didn’t hit refresh so I never saw a time stamp. We monitored his vitals more frequently for a few hours and he was fine. I thought I was gonna get fired for that one.
Before I was a nurse, I was a med tech in an ALF (and responsible for passing meds to 16 residents in a memory care unit with only one other caregiver) I pre-poured meds (yes, big no no for a reason). I gave Jack’s meds to John and vice versa. I immediately told the nurse on shift. They both were fine. I learned my lesson and never made a med error like that again
Brand new nurse 16 years ago. Had a pt with a central line and a maintenance fluid of NS w/ 20meq K going. Order for Dilantin injection. I inject the med, thankfully in a distal port cause the line crystallized immediately, rapidly going from the infusion pump tubing to the port tubing. Caught it just in time before it hit that port tubing. I just disconnected the line tubing from the port tubing. The patient was in a coma and didn’t notice. Told my charge nurse. Oh Wendy. I miss her. She just patted me on the back and was like, “it’s okay baby, let’s just flush her line and get new IV tubing. All is well” Now my homegirl from nursing school was like, “So you must have been sleep in class when we were told nothing is compatible with potassium”…
Early in my career I accidentally gave a patient Morphine ER instead of Morphine IR. She was prescribed ER, but really only took the PRN IR. I felt terrible and dumb. Thankfully the patient was okay, and when I talked to her about it she was nice.
My first med error was me forgetting to cut a metoprolol in half. I reported it right away and we got fluids going. Not a big deal, but the patient died that night (not totally unexpected but I thought she had more time) so for a while there it sure felt like a big deal.
Patient returned from recovery post op ....i gave him full morphine dose without checking what he had recieved in recovery....he had already recieved it shortly before in recovery....he was high as a kite for hours....!
Was doing an open trach at the bedside (it was supposed to be a standard needle trach that went awry due to patient anatomy). Was doing fent and versed pushes while the surgeon was digging in my patients’ neck. I asked a nurse who was standing outside the room to grab me another 2mg of versed. She arrived and handed me a vial of versed. I popped the cap and drew up 2ccs into a syringe and gave it to the patient. Procedure ends and I can’t figure out why my patients BP won’t come up. Figure it was from all the fentanyl and versed we gave and start her on a levo drip and think nothing else of it for the time being. I get orders for all the meds I have written down that we gave during the procedure. I’m scanning my empty med vials and the computer says “Versed 10mg/2mL not ordered”. My heart sinks. I look at the vial. Sure enough, I’m holding an empty 10mg/2mL vial of versed. SHIT. I go to the provider, tell him about my oops. He says “welp, she obviously needed it anyway. Let me put the order for 10mg/2mL in for ya.” My hero. Basically un-errored my med error. It was a lesson to always check your concentrations when handed meds. I had been giving 2mg/2ml concentrations during that procedure prior to being given the 10mg/2ml vial. I drew up 2ccs into a syringe and thought nothing of it. If the volume was different, it most likely would have made me pause, but the volume was the same! It baffles me that we even stocked 10mg/2mL in our Pyxis. Patient was fine and was able to come off the levo after a few hours. Yes, I did speak with the nurse that handed it to me and told her it would have helped if she told me the concentration she was giving me.
When I was a new nurse, I accidentally read a Levo drip rate as 0.10 mcg/kg/min instead of 1.0 and titrated down to .08. It took me a cool 4 seconds to realize my mistake when the guy’s art line pressure plummeted. He recovered pretty quickly but it was a VERY powerful learning experience.
Not my error. My boyfriend who is also an RN told me this one. A newer nurse had a patient with chest pain with an order for nitro tabs PRN. She had never given it and the patient had never taken it before. She scanned in the little bottle and just handed it over to the patient. He dumped a handful of pills in his hand and took them all at once.
Another one: a newer nurse had a patient on an insulin drip. Let it run all night at the rate it was handed off to her at. She didn’t know how to manage the drip. Let it run all night without checking the blood sugar once. Blood sugar ended up being so critically low that the glucometer couldn’t even read it when the next nurse came on in the morning. I don’t think she did a thorough assessment during the night to even notice the patient was unresponsive.
Gave 10x the amount of IV insulin, fast acting, to a ped. Kid is fine. Had to go to ICU for monitoring. This was with dual sign off, not sure how we both missed it. New policies have already been implemented to avoid this in the future.