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The one mistake every nurse shouldn’t make

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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 read 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.

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Sean Dent

Sean Dent is a second-degree nurse who has worked in telemetry, orthopedics, surgical services, oncology and at times as a travel nurse. He is a CCRN certified critical care nurse where he's worked in cardiac, surgical as well as trauma intensive care nursing. After five years practicing as an RN, Sean pursued and attained his Masters of Science in Nursing. Sean currently practices as a Board Certified Acute Care Nurse Practitioner (ACNP-BC) in a Shock Trauma urban teaching hospital. He has been in healthcare for almost 20 years. He originally received a bachelor's degree in Exercise and Sport Science where he worked as a Certified Athletic Trainer (ATC).
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36 Responses to The one mistake every nurse shouldn’t make

  1. amy mickschl

    Hey sean,
    great post. i absolutely agree.

  2. sandy cooper

    great advice. as nurse’s we can’t forget that we are human. we must be honest enought to admit when we make mistakes as well

  3. Sean Dent Scrubs Blogger

    @ Amy Thanks!

  4. Great advice! When I was working on my pre-reqs for nursing school, I always got great grades but now I find myself struggling in nursing school. One thing I can tell you for sure is that all of my “mistakes” are doing me much more good than harm. I’m finally starting to realize that having a good grade doesn’t necessarily mean that I’m LEARNING anything. Getting an A with no mistakes looks good on the grade sheet, but getting a C with lots of mistakes, but many lessons learned, will actually be much more beneficial to me…and my future patients.

  5. Sean Dent Scrubs Blogger

    @ John Well said! Your perspective is going to take you far in this career, don’t lose that.

  6. Jenna Olds

    Hi Sean,
    I’m in my first semester of nursing school and I just wanted to say thank you so much for this post.
    Like John, I got excellent grades through my pre-reqs and felt confident that I would do well in nursing school. While I still get A’s, when it comes to skills, I’ve had my confidence shaken several times. Actually, reading your post couldn’t have come at a better time for me. Today, I was practicing IM injections for the first time with my lab partner. SubQ and transdermal went fine, so I figured IM would go just as well. Not so much.
    Everything started off fine. I inserted the needle with a darting motion and I was about to aspirate when my instructor and I noticed the look on my lab partners face. We asked if she was ok and she told us that her fingers were tingling, so I immediately withdrew the needle. On my first deltoid IM, I managed to hit a nerve. My confidence fell through the floor and I’ve been plagued for the rest of the day, thinking “I’m terrified I’m going to be a bad nurse!”
    My instructor and I discussed what happened and she assured that my technique was good and that hitting a nerve doesn’t happen very often, but I couldn’t help thinking I had done something wrong.

    Anyway (I know this has been a bit long winded), I came home and when I read your post it reminded me that none of us are perfect, I will try again, I know what can happen and what to do if it does, and that not everything is going to go as smoothly as I want it to everytime.
    Thank you again!

    • SeasaltAndRedClay

      Hi Jenna, thank you for sharing an experience with which we are all familiar. If this had happened to me with the instructor I have currently, my written evaluation would have stated that I was “unsafe in the clinical setting”. I know this is true, because I had a patient who was on Contact precautions, requiring gloves, gown, and mask r/t inconclusive MRSA results. I stepped into the room solely for the purpose of checking her IV flow rate as compared to Dr.s orders. I touched nothing. However my instructor saw me in the room with nothing but gloves on & called it to my attention; I accepted her criticism & agreed I should have gowned & masked, just in case I might have suddenly needed to make direct contact with the patient (She was sleeping & showing no distress: no excuse) I was in and out of her room at least another 8 times that morning, and each time I gowned, gloved, and masked; at least twice I saw my instructor walk by the room & look in & she clearly saw I was in compliance. My mid-term evaluation for patient safety was Unsatisfactory & the reason was for entering an isolation room with proper attire. Nowhere on my entire eval form did she state that I learn from my mistakes. I wish I had your instructor.

      • SeasaltAndRedClay

        Sorry, I obviously meant “entering an isolation room WITHOUT proper attire” :)

  7. Sean Dent Scrubs Blogger

    @ Jenna – Wow. Thank you so very much for sharing your story. You and your instructor are 100% correct. The best accomplishments are in the face of the worst fears. Keep your head up!
    Thanks for visiting and commenting. :)

  8. Sean Dent Scrubs Blogger

    @ Sandy – thank you. We ‘super-human’ nurses have to be reminded of that.

  9. Allen

    Sean,
    I can relate. As nurses we are juggling caring for the patients, checking the charts, receiving phone calls, sending patients for tests, administering medications, delegating to uncooperative staff, (anybody else?) and so on. Mistakes are made and we feel horrible when it does happen but we are only human.

  10. Sean Dent Scrubs Blogger

    @ Allen well said. We humans need to remember that.

  11. Renea

    I have been nursing for 2 years now and I still find myself horrified of making mistakes. I had an issue where I hung an antibiotic for a patient with the incorrect name! Fortunately, the medicine was correct with the correct dose and time so the patient was not harmed. However, I felt so bad after that, What if it had been something the patient was allergic to? We have people’s lives in our hands!! We have to be so careful. Thank you for your post! It definitely is something we nurses should live by!

  12. Sean Dent Scrubs Blogger

    @ Renea You are welcome, glad you found it informative.

  13. Ani Burr Scrubs Blogger

    Sean, thanks for posting this. I’ve actually made this exact mistake! Especially as students, we’re so caught up in the skills that we forget the basics, but even so, when you’re so new to nursing, moving a bed up and down ISN’T all that basic… I mean, my bed doesn’t move up and down… why would that cross our minds?? But with time, and hopefully harm-less mistakes, we start to adapt. These are the things that teach us more than any text book “how-to” can. Thanks for the post!

  14. Sean Dent Scrubs Blogger

    @ Ani You are very welcome, glad you liked. Yes, the textbooks can’t teach us the most important lessons to learn.

  15. One of the things that stuck on my mind from our instructors way back nursing school is, “always ask if you’re not sure of something or in doubt.”

    Not too long ago we made a mistake on carrying out a new oral medication (tablet) order but was immediately placed on  hold by the physician by writing “=>hold” next to it.  But the problem was it look like this “=>H2O.” I asked the charge nurse, “is that H2O?” He said, “probably.”

    The order itself was weird.  I think it’s pretty well understood you need water to take a tablet.  I knew that I had to ask the doctor but it felt kind of stupid. 

    So we assumed it was H2O until the next day when the doc found out.  She was half mad, half laughing.  No harm was done to the patient though. 

    Now I’d like to add a bit of a phrase to what I’ve learned in nursing school.

    “Always ask if you’re not sure with something or in doubt, no matter how stupid you feel.”

  16. Sean Dent Scrubs Blogger

    @ Earl You and me both! I remember that all too well. Thank you for the reminder!

  17. Kim

    Wow, does this ever sound like something I could have written. I worry so much about the details – gloves on, gloves off, rails up, bed down, call bell in place. When I’m getting evaluated by my clinical instructor some of these things go out the window. Our first rotation was in a long term care facility that seemed to be a little disorganized. I was desperate to find some equipment or another, and I walked right out of a patient’s room with my gloves on. And my instructor was right there. GAH! I feel like I’ll remember that moment forever.

  18. Sean Dent Scrubs Blogger

    @ Kim And thanks to that incident, you’ll never forget! Thanks for sharing.

  19. Karen

    I love this article-recently went through a situation and am still beating myself up about it though will for sure learn from my mistakes-wish there was a better way for something to get that deep into your memory

  20. tami

    awesome article as a long time nusre going back to further her education reading the replys made me think of clinicals and the things I tell the nursing students… always always ask.. the only stupid question or mistake is the one you never ask or lean from!!

    • Sean Dent Scrubs Blogger

      @Tami well said. Very true: the only stupid question is the one never asked.

  21. TJT

    I walked into a patient’s room just last night and found this same mistake was left by a nurse with YEARS of experience…some of them NEVER learn.

    • Sean Dent Scrubs Blogger

      @TJT It may take the courage of their fellow co-workers to help them see the light.

  22. tanya canto

    great posts!

  23. phyllis

    I’ve been a nurse for thirty years, and I have also been a patient. Life is alittle different on the other side of the stethescope. A nurse came to give me my medication,plunked it down, “here’s your medication” . She never asked my name, I told her that it wasn’t my medication, I don’t get eye drops, she insisted they were mine, I told her my name is not Dorothy. ” oh”. turned and walked out of the room.,If I had been confused ,she my have gotten away with it. When passing medication, always, always,always check and double check and then check again , a medication error can be fatal.

    • Sean Dent Scrubs Blogger

      @phyllis Thank you for sharing your story. You couldn’t be more right.

  24. SeasaltAndRedClay

    I want to thank you for this advice; I happened upon it as I am in an almost unbearable situation with my Nursing III clinical instructor (LPN to RN transition program at a highly regarded state college; I have 17 yrs prior lpn experience) To me, what you are saying is what clinicals, as well as day to day professional nursing, are all about: as students we are going to make mistakes, but are they different mistakes are just repetitions of the originals? Evaluation of student learning comes down to how the student accepted the criticism in the first place, and whether each ensuing opportunity with that same procedure demonstrates consistent progression in the technique, and finally mastery. This happened to me, and I was nevertheless demerited to an Unsatisfactory in my first half of clinicals. One notation was that I didn’t know where the Procedures & Protocol book was located … it was on the hospital computer, and even my instructor had a problem bringing it up. She never again questioned me on how to find the P&P, in order to see if I had learned this. She also completely omitted the fact that the reason I was looking for the book was because I needed to do C-diff stool culture — a procedure I’ve never done, and as it turned out, none of the hospital staff nurses I asked knew which containers to use for C-diff, or where to find them. One nurse finally led the way. In the end, I was able to gather all supplies, have them ready at bedside, and state why using gloves to obtain an anal specimen and or using tongue depressors to transfer the stool to the containers are not appropriate due to chemicals used in the manufacture of gloves & tongue depressors. I was able, and waiting, for my instructor to ask me to define C-diff, but she did not do so. She never commented in any way about what I HAD done, but on my evaluation, she wrote simply “Did not know where to find P&P”, and gave me an Unsatisfactory in the area of orientation to unit. All in all, I got an unsatisfactory for less than a handful of things that were one time occurrences — not being sure how to operate a particular type of double sided pump, for example, one we had no practice on in lab — we used the archaic blue & white Baxter for check-offs — and asking my instructor to show me how to use the more sophisticated electronic pump. Again, even she had difficulty figuring it out, yet my evaluation stated I wasn’t proficient with IV pumps. I could fill up 6 or 7 pages with similar information. We finally had a meeting with the head of the nursing department, and the instructor looked her squarely in the face and outright lied about numerous issues. I actually believe she was enjoying knowing that I knew she was lying and could do nothing about it but reiterate the facts. The dean sided with the instructor, told me to start taking responsibility for my own behavior, and reminded me I was lucky to still be in the program. I believe this instructor has make up her mind to oust me. I am 58 years old and just now going for my ADN. My instructor is my age, but she has a Masters & is working on her Doctorate. It has occurred to me she may think I am too old to be just now entering the arena of registered nursing. So, once again, thank you for stating so eloquently what I already knew: human beings learn new tasks by first not doing them perfectly and then building on each piece of knowledge gained as a result. The identifier is whether the student is learning, progressing, growing. I know I am accomplishing those thing daily, and I also know I am probably going to fail Nursing III.

  25. Nurse Rene RN

    Even the most seasoned, educated nurse/doctor sometimes cannot ‘see the trees for the forest’. The BIG Thing gets in the way and we can ever so easily ‘miss’ the small stuff. Still, these are the lessons that you NEVER forget!

  26. Peg Olsen

    Hi, Sean!
    I have been an RN for over twenty years.Clinical experience is very important. I started as a CNA and worked my way through 20 years of school to obtain my ADN and eventually, my BSN. Throughout the time, I found more and more, that theory is nice to know, but practical, competent application of the theory is more important. The way to achieve that is with on-the-job training. It’s an old-time phrase, but it certainly applies to any mentor program or intern program, etc. that hospitals now have. However, new grads need to remember something. Just because you graduated and passed NCLEX, the learning never stops! Be receptive, take initiative and be observant.

  27. erinlynnalaska

    As a nursing student I recently have learned this lesson. I do great in school, I get a’s and b’s, and work my butt off. However for the first time on a real person, I was told to put in an IV. In our lab it was so easy. On a real person I was terrified. I got the catheter in, but blood was everywhere. The more blood that came out, the more flustered I became. I was a wreck the rest of the day. It really broke my condfidence. This couldn’t have come at a better time. Thanks!

  28. gelele

    I believe that mistakes are unavoidable especially at the beginning of your career. It is part of the learning process. In school I was very unforgiving of my mistakes as my classmates were of theirs but after having an instructor who taught me to stay focused on improving my skills and not obsessing about what was done, I felt more positive. Especially, because most of us are conscientious about what we do.

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