So I know when you read the title all you could think about was ‘what is it??!’ Anyone who is a nurse or on their way to being a nurse can use this piece of advice!
We live in the world of life and death.
I don’t think anyone will argue with me on that. We can have many levels of definition when we are asked what a ‘bad day’ really is. In the end, we shoulder a lot of responsibility caring for our patients, and we sure don’t want to make ‘that one mistake’. We’ve all made mistakes. I know I have. Some small, some great, some breath-taking, and some are quite comical. At the end of the day we are all human right? Aren’t we entitle to tripping up once in a while?
I think it has a lot to do with HOW we learned of our mistake sometimes that can determine how that mistake impacts us. In nursing school I remember a patient of mine having an IV site issue. The nurse caring for him did some adjustments to his IV site. While addressing the IV, she raised the bed up high enough to be close to waist-height (more than likely to lessen the strain on her back while troubleshooting). That particular day it was my big day to hang my first IV. I got to prime the tubing, lock it into the IV pump and then attach it to the patient (I think we all remember that first time). I was nervous as all get out. I had followed the steps prior to entering the room. I rehearsed them in my head before I approached the IV pump. I check and triple checked the tubing. Reviewed the 7 rights, etc., etc.
I successfully hung the med and had it infusing properly with no alarms and no messes! When I was getting ready to leave the patients bedside, my nursing instructor asked if I forgot anything? Silently in my head I panicked and retraced all my steps four more times. Check, check, re-check.
I paused before answering no, that everything was fine.
The nursing instructor asked me a second time. I re-traced my steps, 4 more checks over my work. I replied again with an ‘Aye-oh-OK’ response.
This dialogue happened two more times before the patient finally looked over at me and kindly (and jokingly) said,
“She’s obviously trying to tell ya something”.
I still for the life of me couldn’t figure it out??
My instructor kindly replies, “Well, good job on the IV, but if Mr. Smith wants to get out of bed to use the restroom or anything else he’s going to have to jump (and maybe fall).”
I looked at the bed – and it was still at waist-height! I got so involved in my task that I forgot that the nurse had raised his bed for that IV site troubleshoot!
I was mortified. I had missed something so basic, so simple, yet SO very important. To this day I tell that story to any and all that will listen. I have never left my patient’s bed at an unsafe height. Every time I leave my patient’s room I always, always, always lower the bed to its lowest setting. The way I learned that lesson has remained engrained in my brain.
I’ve made many more mistakes since then. Some even more comical, and some down right scary. I once entered in the wrong infusion settings for a narcotic medication for a patient. I transposed concentration and total amount of drug settings on the IV pump. Lets just say, thankfully the patient was intubated and the mistake was found quickly.
So back to my original statement : What is the one mistake every nurse shouldn’t make??
The mistake that they do not learn from.
Learning from your mistakes is the single most important process of growing and maturing as a practitioner. Not learning from a mistake will set you up to make that same mistake again.
Be sure to learn from all your mistakes, no matter how great or small, your patients will thank you for it.
My mistake was not learning sooner to C.Y.A. I have been an RN for 20 years most of those in psychiatry but I have worked in just about every field of nursing. In Psych it’s different for some reason though. We have each other’s backs and we aren’t out to get one another all the time. When I left psych after a major automobile accident that left me with a TBI, I was out of work for two years. When I went back, it was to a long term care facility and rehab. Talk about back stabbing and catty. As a result of that experience, (watching what happened to a couple of fellow nurses there), I ALWAYS have a witness with me when I pull narcs now AND when I administer them. That way there is no way any untrue accusations can be made. My advice to anyone working in long term care is to do the same!
First semester of nursing school, working 11-7 in LTC to pay for it. The charge nurse was an old Army nurse who worked harder than anyone. She was not impressed with my attempts to study in between rounds. “You think you’re so damn smart? What’s wrong with this?” as she hurled a vial at me from the code cart she was checking. It looked fine to me. “It’s expired!”
I never forgot to check the expiration date again!
I’m a very old RN, MSN (30 + years in nursing). My advice to all of the Nurses that enjoy patient care, like to be at the bedside to do the teaching, exams that find that problem early, and generally love knowing what to do and how it’s done……….DO NOT, go into management. Not for the money especially. I left bedside and cardiac nursing (loved it) and took a job as a informatics nurse and later a Director of Patient Care Services. This is my one regret in my nursing career. I should have been an NP, but instead I got stuck in management.
Someone out there…..Learn from my mistake. All you nurses, Have a wonderful, fulfilling career 🙂
Great article! It brought me back to the days when I first graduated nursing school and got my first job on the telemetry floor. Talk about nervous!
Thank you again for the great article.
Bed BRAKES! I get soooo very frustrated with people who always forget to lock the beds/stretchers…..too many times I have walked up to a bed/stretcher that someone has just moved and walked away from without locking it………The mean part of me wants to leave it unlocked to “teach someone a lesson”. The patient safety first person in me always walks up to the bed/stretcher and locks it so the patient is safe…….
Very good story. Enjoyed it and remembered the days of my nursing instructor.
Oh yes! As trivial as the bed lowering mistake seems, things like that can have huge ramifications. I am a new nurse and in a very busy ED. I had a patient in a-fib w RVR who was not responding to any mess. We bonuses Cardizem and then hung it, my first drip. We needed to get her BP down and my preceptor and I talked about metoprolol, etc etc so I drew it up and was ready to go. She was not in the room and I wasn’t sure if I should go ahead since its a pretty basic drug. We had never had a drip before so I was used to simply putting it in the lower port of the IV tubing. It even crossed my mind of the drugs were compatible but I figured cardiac meds had to be. Like a fool, I pushed it through and the patient had some itching but nothing too serious. Not only did I mistakenly push Cardizem through the line (me thinking of it like saline when done in the past) but I also failed to make sure they could even go in the same line. I will always double check the compatibility and make sure I know what I have running in a line before pushing it. I’m embarrassed about it and think it is due to no floor experience where that would have never been an oversight but who’s to say it wouldn’t have happened up there either? Either way, I learned from that mistake and am very concious about not only the drugs but most importantly ASKING no matter how stupid or obvious it might seem. It could save your patient and yourself.