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Dodged a bullet

Image: Blend Images Photography | Veer

As a nurse we have hundreds, if not thousands of things to do and remember each and every day.  We have become masters of multitasking, or so we think.  Is it any wonder that we make mistakes?  The biggest part is trying to minimize the damage of those mistakes, take responsibility for our mistakes and learn from those mistakes so we don’t make them again.

I have my fair share of mistakes too, here is one of my most memorable, that thankfully did not hurt anyone, but taught me a lesson I will never forget.

When I was a new RN in an extremely busy emergency room, right off orientation, I had a patient come in for diabetic ketoacidosis (DKA).  This is the first time I had actually cared for a patient in DKA, and I really didn’t know what I was doing, but it was a busy day in the ED so I didn’t ask for help. 

I got an order for regular insulin 10 units IV push.  But, it was hand written, and I read the order as regular insulin 100 IV push, because the u was written so that the top parts of the U intersected and looked like another zero.  I went and drew up the insulin, which took two syringes, which should have been my first warning, actually about my fifth or sixth warning.  I remember thinking, this is not right, but I have never taken care of a DKA patient before, so it must be right.

I gave the insulin and instantly thought, I should ask.  After I did it, I went to the physician who wrote the order and she stated it was 10 units.  I thought I was going to pass out, I thought I killed the guy.

His blood sugar was around 800 when he came in.  I immediately told the physician and the charge nurse.  I started taking blood sugars every 5 minutes for the next couple of hours while he was in the ED before we transferred him to the ED.

His blood sugar never dropped more than 10 points the entire two hours.  After he was transferred to the ICU, I kept looking up his labs, and it still didn’t drop after about 8 hours.  The next morning when I got to work, I went up to the ICU and his blood sugar was still in the 600’s.

I dodged a huge bullet.  I could have, or probably should have, killed this guy.  I was reckless for not asking the physician.  I was irresponsible for not asking for help.  I was foolish for trying to take care of a patient was not qualified, or prepared to care for.

I did learn from this incident.  I learned to ask for help.  I learned to ask for clarification.  And most importantly, I learned to stop and critically think before I act.

This is one of my major ones, but I have a ton of them if you ever want to hear them.

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Rob Cameron

Rob Cameron is currently a staff nurse in a level II trauma center. He has primarily been an ED nurse for most of his career, but he has also been a nurse manager for Surgical Trauma and Telemetry unit. He has worked in Med/Surg, Critical Care, Hospice, Rehab, an extremely busy cardiology clinic and pretty much anywhere he's been needed. Prior to his career in nursing, Rob worked in healthcare finance and management. Rob feels this experience has given him a perspective on nursing that many never see. He loves nursing because of all the options he has within the field. He is currently a grad student working on an MSN in nursing leadership, and teaches clinicals at a local university. Away from work, Rob spends all of his time with his wife and daughter. He enjoys cycling and Crossfit. He is a die hard NASCAR fan. Sundays you can find Rob watching the race with his daughter.
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5 Responses to Dodged a bullet

  1. Victor

    Thank you for being brave enough to share your story.

  2. Alice Janette Mann

    I graduated from nursing school in 1981 and was asked what area of nursing I was interested in working. I replied “anywhere but Cardiac..” I found that area to be so intimidating and down right scary. Well, to my HORROR, I was placed right on the Cardiac Care Unit. I think I cried everyday for months, feeling so inadequate and down right stupid. It took me a good year of learning to read EKG’s , ect. before I felt a little bit comfortable. After being on the unit for 17years, I loved my job and became a charge nurse! I made a terrible mistake one day, pulled up meds, walked right into the wrong room and gave the meds. I knew right away I had made a mistake and called his doctor. Boy, it only takes one time and you learn. If any nurse ever tells you they have never made a mistake, I wouldn’t trust them!!!!!

  3. Noreen

    I had a very scary learning experience about a year after i began working as an RN on the med surg floor where I had been a CNA for 5 yrs prior! I felt sooo comfortable that i got very cavalier and careless. If the IV supply drwer said 500cc NS then that’s what MUST BE in the drawer. I picked out a bag, pierced it , hung it left the room for 10 minutes and tWhen I came back to hang the antibiotics I discovered to my horror that i had hung NS WITH 25000 units of HEPARIN!!!!! Thankfully i took it right down and the patient was unharmed but I learned to slow down and READ EVERYTHING !! That’s why they spell ASSUME the way they do!!! It makes an “a**” out of “u” and “me” when you don’t take your time and pay attention to everything you do, no matter how “simple” it may seem!

  4. Linsey

    Thank you very much to all who have shared their stories. I am a firm believer that a nurse that says that they have never made a mistake is a nurse that should never ever ever be trusted. Not even in a crisis and they are the only person in the hospital…they are too perfect and perfect people have never had that gut check moment where you are like “Oh, crap. That was really close. I have to be more careful! I could have really hurt that patient.” When a nurse is perfect, they have no where to improve to.

  5. Renea

    All I am going to say is AMEN to this last comment, Linsey!! I agree with you 100%!