Errors Committed By New Grads & Experienced Nurses
Learn from these errors so you don't make them!
giving a beta blocker without checking the blood pressure or heart rate
A patient was on Metoprolol (a beta blocker) for elevated heart rate
The dose wasn't really fixing the heart rate and the blood pressure had been normal
The MD then increased the dose from 50mg to 100mg and received the first 100mg dose at around 1000
The next scheduled dose was for 2100, so the nurse gave the 100mg dose at 2100 (but never looked back to see past BP readings. Maybe because the RN was thinking only HR since this was the reason for the prescription?)
What was the problem?
The nurse never looked at the blood pressure throughout the afternoon
The nurse did not check the blood pressure immediately prior to giving the 100mg metoprolol
Don't skip this step. MAKE IT A HABIT to check before giving any medication that can affect HR or BP
The blood pressure
The BP had been trending down the entire afternoon
The most recent BP (at 1900) was 92/50 in a patient whose BPs the previous days were 120-130/70-85
The heart rate had improved though!
The patient felt dizzy around 2200
The nurse checked the BP at 2200, and it was approximately 80/50. The patient was not tachycardic (since the metoprolol was blocking its ability to speed up).
And this is when the nurse felt really bad and embarrassed
These feelings could have been 100% avoidable
What can you learn from this?
Always check the parameter that the medication you are giving is going to affect
In this case heart rate and blood pressure
DO this BEFORE giving the medication
Also look at heart rate and blood pressure trends
If it is a medication that affects pottasium or coagulation times, look at those labs first!
If you see large changes in the HR and BP trends, tell the MD
Make sure parameters are ordered by the MD
Example: "Hold metoprolol for systolic BP <100 or HR <60" (this also protects you legally)
Or whatever is appropriate for your patient population
If parameters are not ordered, call and get them ordered & use your brain & think about the medication
Although, not something you need to call at 2AM for however!
If you do make a mistake (like the one above), do not try to cover it up
Call the MD, just be honest
does a patient in cardiac arrest need their tube feeds going?...no, no they do not
...not only does a patient in cardiac arrest receiving CPR not require tube feeds, but it can actually greatly complicate matters. The problem is, during a code, people have their minds on so many things: drug doses, feeling a pulse, setting up the defribrillator, performing chest compressions, etc...it is understandable that we often forget to turn off the tube feeds.
What happens during a code? Patient is placed into a flat position, given breaths via an AMBU bag (which is notoriosly difficult to do, so air fills up the stomach). These things lead to vomiting and aspiration. Now, the patient has to not only battle a cardiac arrest, but now a possible apiration pneumonia. Intubation can be made more difficult with vomitus in the airway.
Inevitably, someone will get mad at the bedside nurse for not having turned off the tube feeds!
Traditionally, there has also existed fear about starting tube feeds early after a cardiac arrest or if patient is on vasopressor medications. The thought has been that, with tube feeds in these situations, hemodynamics may become unstable (blood would be diverted to the gut instead of to more vital organs) or, in the case of vasopressors, ischemia to the gut could occur, making digestion difficult and vomiting would ensue. There are arguments against these theories, but it does provide food for thought (no pun intended). Read more about this topic here.
Confirm placement of NG tube before feeding!
This is mistake is so common! And it is one of the easiest mistakes to avoid!
Pediatric nurse placed an NG tube and immediately started running feeds through the tube
Problem was, the tube was not in the stomach, rather it was in the lungs
Short time after, the patient's O2 sats dropped, xray revealed one lung was completely "whited out"
Patient was intubated, moved to ICU
The time spent at the hospital and costs soared
What can you learn from this?
Always, Always, ALWAYS check the placement of the feeding tube
It is easier than you might think to place the tube into the lungs
Do NOT start feeds or give meds through that tube until you have:
X-ray confirmation of correct placement
I don't care if mom/dad or MD are screaming at you to start feeds or give meds, you get an X-ray FIRST
Actually read the radiologist report and look at the xray
Or appropriate pH (if gastric, pH should be ~1.5-3.5, higher if intestinal) of aspirated contents
What if you come on shift and the tube is already in place?
Check the palcement:
you can aspirate contents, test contents, instill air and listen with a stethoscope, see if patient gulps when put in air or remove/replace stomach contents
These tubes can move around and get coiled up, it happens all the time
NG Tube placed into the lung
NG tube correctly placed into the stomach
See the difference?
too much demerol
This is similar to the metoprolol story
Too much meperidine (Demerol, a narcotic)
Patient had Demerol scheduled every 4 hours after a lung related surgery
Demerol is sometimes restricted baed on the unit
Allowed in ICU & IMC but not allowed on a med-surg floor
It is often just used in the PACU to recover patients after surgery
In this story, the patient was on a IMC floor, so the nurse knew that Demerol could be given
The patient was in pain and asking for pain medicine complaining of severe pain
Demerol was ordered every 4 hours and was due at the same time the patient wanted pain medicine
So the nurse gave Demerol, which was fine
The problem came when, 4 hours later, the patient was in pain, but not enough to justify Demerol
Patient was reporting minor to moderate pain
Demerol can absolutely knock people out!
So every 4 hours the nurse gave Demerol
The first time was fine and justified
The second time, the nurse only gave it because it was ordered even though the patient wasn't having severe pain
The third time, the patient was in mild pain and drowsy, but still had adequate respiratory rate and blood pressures
The nurse only chose Demerol this time because it was ordered
The patient was drowsy (because of the Demerol) & not in a lot of pain
The Demerol was, in this case, only meant to be used in the PACU
What can you learn from this?
Give the pain medicine that matches the pain score
So, don't give Tylenol for a pain score of 10/10 & don't give Demerol for a score of 2/10
Common pain meds used in ICU, IMC, Med-surg are:
Tylenol, Dilaudid, Morhpine, Fentanyl, Percocet and Norco
Scheduled Demerol should make you question "What is going on?"
It could be a valid order, but look into a bit deeper
If a patient is getting overly drowsy be careful with pain meds
Certainly do not give a stronger pain medicine if the patient is drowsy and reporting lower pain scores
Respiratory depression is close to follow
I forgot to assess that...
This is a story of a very busy nurse that did not fully assess the patient
The patient was having foot pain, so the nurse gave the patient pain medicine
A few hours later, still having foot pain. The nurse gave more pain medicine
Come morning time, the MD came to round on the patient...What did the MD find?
Was there a pulse? Only in 1 foot, there was no detectable pulse in the foot that was cold and painful
That patient needed surgery to restore blood flow to the foot
One foot that was larger, much cooler, and a different color than the other foot
The MD was not happy and the nurse was very embarrassed, and of course, it was avoidable!
What can you learn from this?
Do a basic assessment! Get into a habit and a routine! (A lack of routine was part of the problem in the IV related mistake lower on this page)
It will make your life so much easier (work smarter not harder)
Even if you do not know what to make of a particular finding, some one else will and at least any problems can be fixed
And you stay out of trouble!
So actually take the time to assess
It should only take about 1-5 minutes (5 minutes would be on a very sick patient)
But can save you hours of time and a huge headache in the future
This is a story of a new nurse that had never heard of a Trialysis line before (see pic below). Do you know your lines and tubes? For a review see the lines and tubes section
What went wrong?
The nurse was infusing IV antibiotics and IV medications through the dialysis lines as well as the pigtail
Again, this nurse did not know anything about the line, and thought all 3 lumens where the same
The nurse also drew blood from the dialysis lines and not from the pigtail line
These actions compromise the line and make it a high risk for clotting and the need for a new line to be placed
What is the correct way to use a Trialysis?
For giving medicines and/or drawing blood, use ONLY the pigtail
Unless you are the dialysis nurse, you won't be touching the other ports (except to 'pack' the ports)
The dialysis ports are for Dialysis only!
When dialysis is completed, these ports will be packed (filled) with an anticoagulant
So if you are giving medicine or drawing blood from these ports, you are removing the anticoagulant and thus increasing the chance of a clot and the need of a new line
What can go wrong with an anticoagulant?
If you have read the other medication related errors on this page, you will notice a common theme: too often nurses give a medication 'just because it is ordered' but without checking all the parameters (whether it be labs values, vital signs, or patient assessment) that the medication is going to affect.
Lovenox was ordered for 0600, which the nurse gave
The problem was the nurse did not look at labs
The patient had critically low platelets (the platelets had been dropping over several days)
Hemoglobin was low
The creatinine was slightly high
Coagulation times were not available
So in short, the nuse should never have given the lovenox. Luckily, no harm was done, but it put the patient in a more vulnerable state.
What can you learn from this?
Always check the parameters that the medication is going to affect
This is why you need to know about the science behind the medication you are giving!
For anticoagulants check:
Coagulation times (PT, PTT, INR)
Platelet, hemoglobin, RBC level
Creatinine (elevated creatinine is actually a contraindication for Lovenox. Usually the MD will switch it to Heparin at this point)
If coagulation times are greatly prolonged (if the patient is on a blood thinner, we expect prolongation of coagulation times) talk to a pharmacist or MD prior to giving
If hemoglobin is suddenly low, is it possible the patient is bleeding? If yes, then a blood thinner is a bad idea!
do the ivs work?
A nurse was assigned to a patient that 16hrs earlier had coded
During the code, the patient received several units of blood and several boluses of fluid
Now the patient had no further episodes or issues
The patient was receiving maintenance fluid, sedation had been turned off
Patient had only 2 peripheral IVs, Intensivists had plans to place a central line
All of the sudden the patient presented with bradycardia and severe hypotension
A verbal order for atropine was given
Guess what? The IVs were not working! And it was apparent that they had not been working for a long time (very likely that they were over-used during the code).
Couldn't give atropine
Patient went into full cardiac arrest after a few minutes
The nurse did recognize that at the start of that shift, the IVs were not checked due to being busy and not having an established routine for patient assessment at shift start.
Check IVs often!
my blood is boiling!
This mistake happened several years ago, and nationwide steps went into place to avoid it from happening again.
So what happened? Well, a patient needed a lot of blood prodcuts, and needed them quickly. The patient's nurse received the blood, which was cool in temperature. The nurse decided to heat up the blood in the microwave for several minutes.
Of course, heating up blood (in a microwave, essentially baking it) changes the chemical nature of the blood. The patient that received the blood died because the blood had hemolyzed (RBCs break open), releasing dangerous levels of electrolytes, such as potassium.
When can (and should) you warm blood?
For massive blood transfusions (when tens to dozens of units of blood needed)
When more thatn 25% of whole blood volume will be given...this will hard to calculate, and you will know when a massive amount of blood is needed!!
When transfusing blood to patients with cold agglutinins (an autoimmune disorder in which a patient has autobodies that attack and destroy RBCs when the patient is in cold environments, or if given cold blood)
How do you warm blood?
ONLY USE a blood warmer machine
Not a microwave!!!
For massive transfusions, don't delay giving the transfusion just to set up the blood warmer
bolus of tpn
This mistake was the product of an over-worked and flustered nurse which led to a critical mistake. Apparently, the nurse had gotten 2 hours behind, while caring for 6 patients. In a hurry, the nurse quickly set up the new TPN bag for the night and programmed the infusion into the pump.
Instead of programming 95ml per hour for the rate, 950ml per hour was entered. around an hour later, the patient had received a bolus of nearly 1 liter of TPN.
Of course, TPN has a high osmolarity and is hypertonic compared to the blood. A fluid shift occured, eventually leading to fluids accumulating in the lungs. The patient went into respiratory distress. A chest X-Ray revealed a "whited-out" left lung, requiring intubation.
What can you learn from this mistake?
1. This kind of mistake can happen to anyone! 2. No matter how busy you are, promise yourself this: "Now matter how busy I am, I will triple check all infusion rates when I start an infusion or change an infusion rate of any medication or solution!"