I recently stumbled upon a social media site on which two nurses were discussing submissions to their question, “What is the biggest nursing mistake you have ever seen?” The answers are disturbing but no surprise to anyone who has looked into the amount of medical malpractice out there. These are the things doctors and nurses talk about among themselves when they don’t believe any of the public is listening.
Among the mistakes submitted to these nurses:
A nurse was ordered to give a patient a stool softener. The softener came in powdered form. She mixed the stool softener powder with tap water and administered it to the patient through an intravenous line instead of by mouth. The patient ended up in the ICU.
A nurse hung an insulin drip at the same time as she hung a bag of normal saline, sterilized water with some salt in it. She mixed up the two bags and gave the insulin at the rate intended for the normal saline, a rate far, far higher than would ever be used for an insulin infusion. The error was only discovered when the insulin bag ran dry. If you know anything about insulin, you know this can be a fatal mistake as it can drive a patient’s blood glucose to so low a level that the patient will die.
A Certified Nurse Anesthetist mistakenly put digoxin, a potent heart rhythm medication, in a patient’s IV line instead of the mild anesthetic that was intended to have been used. The patient died.
A nurse gave a newborn breast milk through a line into the baby’s hand. She later stated she could not tell the difference between the colors for the line going into the baby’s stomach and the one going into the hand.
A bolus is a rapid infusion. Instead of giving an IV bolus of normal saline, a nurse gave a laboring patient a bolus of pitocin, a drug that stimulates contractions. The resulting contractions were so severe that the woman’s uterus ruptured. An emergency Caesarian section was performed, which saved the life of the baby but the mother died.
Coumadin is a potent blood thinner. A nurse received an order to increase the patient’s insulin to 40 units per hour and increase coumadin to 4 milligrams per hour. She went throughout the hospital trying to find 40 milligrams of coumadin. Unfortunately, she was successful in her search and the patient bled to death after she administered all 40 milligrams of coumadin.
A new ICU nurse had a patient whose blood sugar was a little low. Apple juice is a good solution for this minor problem, but not when it is administered through an IV directly into the patient’s bloodstream. No word on what happened to that poor patient.
A nurse was stopped from administering 40 milligrams of potassium through an IV. Potassium in this quantity and by this method would have stopped the patient’s heart.
This post is not intended to single out nurses. Doctors make egregious mistakes as well, often with tragic consequences. The point is that these mistakes occur on a regular basis but are hidden from patients and from the general public. Instead, the public is told that doctors and other health care professionals are being sued over and over for no reason at all which is causing health care bills to rise.
We are never going to be able to fix what is wrong with the delivery of health care until we acknowledge that there is a problem. Denying its existence just means people will keep on dying or being badly injured by avoidable errors.
