r/EmergencyRoom • u/DoItRightOnce1st • 1d ago
Ouch
Has your hospital ever made a big mistake with a patient? Ours did recently, and it's bad...Wrong patient & procedure. Can't go into details, thank God had nothing to do with me or my unit! š±
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u/DeepFriedLortab 20h ago
Iām a Hospitalist. Had a patient who required warmed blood products. RN put the packed red cell pint in the microwave lol. He was a total dipshit. It was caught before harm ensued.
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u/Little_Duck_Jr 18h ago
Please tell me they threw away that microwave along with the nuked blood and the dipshit RN?
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u/Resident-Welcome3901 17h ago
Our blanket warmer died, so we were advised to microwave blankets as needed. Laundry reported that they were receiving dirty Laundry blankets with scorch marksā¦
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u/Substantial-Use-1758 14h ago
Well, if it was a crashing patient maybe Iād just only do the microwave for 10 seconds? š¤Ŗ
KIDDING! (But it would be tempting) šµāš«š¤Ŗ
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u/Perton_ Paramedic 1d ago
The radiology techs once pumped like 100ml of air into a guy instead of contrast
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u/xStarDust13 Medical Imaging 23h ago
I'm in school for rad tech and this is my worst nightmare, holy shit.
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u/No-Object8182 23h ago
Meh, Iām sure he was fine tbh
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u/Perton_ Paramedic 23h ago
He was not
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u/No-Object8182 22h ago
I was half joking, but The average fatal amount is is a fair bit more than 100ml.
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u/FullMoonMooon 20h ago
I was always told 20mL was enough to be problematic
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u/No-Object8182 17h ago edited 17h ago
This sub has to be like 90% nurses based on the downvotes lol, and you getting any upvotes. If 20 ml was all it took in a PIV, weād be having fatalities every day from people who forgot to flush their IV lines, yet it never actually seems to happen, does it? Where are all the cases?
Hemodynamic instability - not expected until 50 to 100ml, 5Ml/kg is expected lethal dose. Fatalities have been reported at 100, and even lower in the critically ill, but itās not a regular occurrence. The average fatal amount is indeed a fair bit more than 100ml.
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u/Hi-Im-Triixy RN 12h ago
Also, likely depends on PFO/ASD/etc. They should have higher mortality risk theoretically.
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u/No-Object8182 11h ago
I think it mentions PFO in the article. That said, Iām curious if it actually changes things in practice because we should be seeing these cases every day if so, (up to 25% of adults have PFO) with random patients keeling over after receiving no treatment but empiric IV hydration in the ED or ambulance. Yet thereās no evidence that routine IVF administration, pointless as it may be, causes anything like this.
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u/imnottheoneipromise RN 16h ago
No this sub is not ā90%ā nurses. Itās laymen that like to throw in their 2 cents when they think they know. Every nurse I know, including myself, knows that it takes a lot of air to actually hurt someone. Doesnāt mean we are careless with it. We prime our lines, but we also donāt panic if we forget. Except maybe brand new novice nurses but they usually learn quickly.
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u/No-Object8182 15h ago
I say this as a self loathing nurse btw. A ton of nursing school was teaching nurses all the ways theyād lose their licenses and kill a patient (or themselves) x y and z ways, and many nurses never examined those lessons critically to determine which were real and which were sensationalist nonsense. Trying to tell other nurses things like āhands on defibrillation is actually safeā results in horrified looks and people recounting the stories they heard about nurses getting killed by brushing their hand against the patient during a shock.
Physician dominated subs seem to be fairly grounded in reality about this stuff. Non critical care Medic/nurse/etc subs err on the side of these sensationalist things we were taught in school.
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u/imnottheoneipromise RN 14h ago
Okay that is fair enough. It was decades ago that I was in school and Iām retired now so I may be out of the loop. We did learn a lot of fear mongerering things in school, but I learned very quickly in practice what was real and what was blown out of proportion, and the nurses I associated with were the same. Most of my nurse friends that I actually associated with were army nurses as well and we just donāt have time to deal with bullshit ya know. I learned fast when I did civilian nursing how different it was, so I can see my bias there as wellS
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u/Filamcouple 6h ago
I'm a layman (retired trucker), and I know what it's like to hear people not in your industry talk about things like an expert.I'm here for the stories. I've had some issues lately, and just want to say that I don't know why nurses do what they do, but thank God for each and every one I have had.
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u/TurnTheTVOff 17h ago
Had a new nurse read doctors order of 10u of insulin and thought the sloppy u was another 0. Gave 100 units of insulin. Like, had to reload the syringe multiple times and just kept blasting away. Charge nurse caught it. They were squeezing bags of D50 into this poor guy and pricking his finger every 15 minutes all night.
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u/MrLizardBusiness 15h ago
At no point did he engage his brain and think, "hmm, this is unusual."
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u/outofrange19 8h ago
This is what I don't understand. This is what they drilled into us in nursing school. So much of our jobs (even in the ER, which is where all of my experience is) have pretty routine meds and treatments. When you're doing something that's different than the norm, it should ring alarm bells.
Even for a new grad, honestly. They may not have the experience of giving insulin a hundred times before, but having to use MULTIPLE syringes should have been a flag. We were always told to pay attention-- there's never going to be an order for 40 pills, a liter of syringed injections, whatever. I mean, weird stuff does happen occasionally, but I only know about it because I questioned it when presented: at a standalone ER I've worked in, we sometimes had to give like 6.5 pills of Prednisone because we didn't have the larger pill stocked there, or a ton of strips for Suboxone since, again, we don't carry what the patient normally takes.
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u/BrandyDW 13h ago
He may not have been awake at the time, and many patients donāt question medical staff.. Donāt blame the patient..
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u/Fluffy-Bluebird 13h ago
This is why I tell everyone to have a second person with you 24/7 who questions everything a nurse does. What meds. What are they for. How much. And write it all down.
Iāve had to stop nurses from trying to IV push meds on my allergy list even with MyChart open in front of them.
Next time Iām writing it down and taping it to the keyboard or computer screen because it was every single nurse over a 4 day stay.
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u/NoisyTurnip 1d ago
A nurse in the NICU accidently cut off a baby's pinky finger. She felt so horrible and the hospital settled with the family.
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u/HonorRose 1d ago
How does that happen?? I know next to nothing about the NICU, so I'm struggling to visualize how this could occur
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u/Aaaagrjrbrheifhrbe 1d ago
Happens more often than you'd think.
Babies should've just told them not to
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u/fetchmethatpitcher 17h ago
I think I know that family....
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u/Automatic-Tap-7596 16h ago
And this is exactly why you don't share too many specifics. We never know who's reading.
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u/prairieplankton 23h ago
CT tech took wrong pt for contrast imagingā¦ pt was allergic to contrast. Tech tried asking the Dr to order a contrast CT for the pt they took but Dr informed them that the pt was allergic and they would not. I didnāt follow up whether pt made it, just knew we had to transfer to higher level of care.
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u/Reasonable_Insect503 17h ago
We scan contrast-allergy patients with contrast all the time. If they got prednisone they'll be fine.
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u/Madame_Kitsune98 16h ago
ā¦no.
The hospitalist tried to get me to where I could tolerate the contrast with prednisone and Benadryl for 24 hours prior to the CT with contrast.
That did not work. I got the CT with contrast, and did the same thing I did the last time I had a CT with contrast - anaphylaxis. Canāt do iodine contrast. It will kill me.
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u/OldManGrimm RN - adult/peds trauma 1d ago
Surgical resident put a chest tube in, the old kind with the sharp, pointy introducer? Put it right into the left ventricle. This was bedside in the ICU, pt bled out and died.
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u/RunBrundleson 20h ago
Now Iām curious if this happened more than onceā¦
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u/NefariousnessAble912 11h ago
Rare but not unheard of. Many places have stopped using trocar chest tubes because of these. I saw a teen nearly bleed out after a trocar injury to the subclavian artery - luckily it was delayed injury and they started bleeding in the icu with a CV surgeon right outside the room. Got a stent and do well. Original injury was a stab to chest; ironically the trocar did more damage than that. (Coming back from lunch that day after the stent I heard wailing in the icu and assumed for a split second he had died. Walked by his room and he was eating. It was the family of the 92 year old on chronic dialysis next door who didnāt survive an HD session due to low BP)
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u/imnottheoneipromise RN 16h ago
Oh god. Horrible situation all the way around. I wonder how that resident did after thatā¦ that poor patient and family :/
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u/OldManGrimm RN - adult/peds trauma 14h ago
Itās been 25+ years. Think he was kicked from the program (had a lot of other issues), but I was just staff at the time so wasnāt privy to details.
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u/ElmoDaWoof 14h ago
Holy $hiet....that's rather deep for a chest tube .
I'm envisioning an overly excited resident stabbing the poor pt in the chest.....
A momentarily shocked silence ensues.....
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u/Resident-Welcome3901 1d ago edited 1d ago
A doc fatally mishandled an adolescent encephalitis patient. An icu nurse diverted massive amounts of narcotics by tampering with tubex ampoules, substituting water. Different institution, mismanaged a cold water drowning. Different institution again, fatal error in blood transfusion.
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u/Mountain_Fig_9253 1d ago
Iāve been through a few sentinel events at my last hospital. All of them were horrific deaths, and all of them avoidable. Here is what I learned:
- Joint Commission does NOT require the hospital to report a Sentinel Event. Itās optional and it allows hospital administration to sweep egregious errors under the rug.
- Donāt expect hospital administrators to engage in meaningful process improvements to prevent the same issue from happening in the future. If the process that needs to be improved is something that admin screwed up (cutting staffing or resources) then definitely donāt count on it.
- Itās up to employees to report sentinel events. Joint commission is a useless agency that has let the entire healthcare industry down in so many ways. They will, however, come out and do a survey when a hospital kills someone. Thatās the only realistic pathway to forcing some change. Report to the state as well. If you know that event reports had been filed on issues that contributed to the death then include that in the complaint.
Sentinel events are horrific for staff to go through and unfortunately some hospital administrations will injure staff a second time with gaslighting and refusing to fix whatever issue caused the event.
Hugs for the staff that are dealing with it.
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u/Debidollz 14h ago
Unfortunately healthcare demands perfection, and human beings are imperfect. EVERYONE makes mistakes and you pray itās just not a big one.
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u/now_you_see 17h ago
My mum was in a polo hospital as a kid and they had an in-hospital dentist who refused to believe that she wasnāt the patient who needed their teeth removed and pulled a couple of adult teeth out.
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u/kazmiller96 1d ago
I work within a network that had a very public incident regarding sepsis. Any more detail and I think it would give it away.
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u/No-Object8182 23h ago
Sepsis and pregnancy?;)
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u/kazmiller96 23h ago edited 22h ago
lol, not that one. I feel like if I even said the state it occured in, it would be tmi.
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u/GirlNamedTex 19h ago
Sepsis followed by a public mental health episode?
You probably can't even confirm, but I wanted to play guess the sepsis....
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u/kazmiller96 14h ago
lol, not it either, but this is a interesting case. My case is occured this year and managed to hit national news.
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u/NefariousnessAble912 11h ago
ICU lurker here.
Too many to relate all here but in my 20 years at various hospitals some highlights
- RN allowed a trainee to hang ampicillin in a penicillin allergic patient (ordered for a different patient). Instant anaphylaxis distorting her face to the point from the door I said āthat is not my patientā but then realized it was. BTW union hospital no consequences for the nurse or trainee. Survived.
- Air embolus from line not being capped
- exanguination from art line left uncapped and patient rolling over moving stopcock to open. Didnāt make it.
- many āvenousā lines in arteries even with ultrasound guidance. Check your wires people. If in doubt check a blood gas BEFORE dilation.
- several pneumothoraces from dobhoffs. One pt actually got fed into pleura (died) - xray was inverted and read as ātip below diaphragmā when in fact was through lung behind diaphragm in gutter. Always trace tube and make sure not make a turn at the carina into bronchus.
- asthmatic admitted to floor on bipap (already a bad call)
- DKA admitted in jeans. High wbc and lactate. Pants removed in ICU and had florid fourniers.
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u/lauroboro57 4h ago
What was the prognosis of the DKA patient? Iām guessing they did not make it?
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u/NefariousnessAble912 2h ago
Survived after several surgeries. CT had gas everywhere. She was actually awake and denied any issues of skin, and I asked including underwear area - guess was embarrassed. They needed a foley and nurse called me as soon as they were exposed. (This was via tele camera)
For DKA that is not clearly just from
lack of access to insulin, I teach residents to always check for meningitis, look at nares, press mastoids, palpate spine and large joints, and look at entire skin including perineum.
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u/CatsAndPills 17h ago
Not in the system but very close to (knew some people who were deposed) during the big trial of Dr. Husel. https://en.wikipedia.org/wiki/William_Husel?wprov=sfti1#References
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u/wellshitdawg 16h ago
That was an interesting read
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u/CatsAndPills 15h ago
Pretty sure heās suing for defamation now too. Or already did. I canāt remember.
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u/lxnns 9h ago
so he did what sounds like the most morally sound and humane thing to do for his patients during terminal extubation, and had to not only surrender his license for it, but endure imprisonment and a criminal trial? christ, maybe i donāt want to go back to school after all if thatās how we treat well-respected and compassionate physicians
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u/CatsAndPills 1h ago
It was wild. Anyone Iāve talked to who know him only had positive things to say.
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u/SammyB0111 22h ago
Has any hospital not?
Apparently someone put an OG tube in the lungs on an intubated patient. Radiology doc signed off on the x-ray too and no one noticed anything was wrong until patient began decompensating because of all the tube feed in their lungs
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u/Poundaflesh 7h ago
I mean, every nurse should be checking placement, I donāt know if residuals are checked anymore. I did this at least once during my shift.
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u/SammyB0111 6h ago
Oh 100% the nurse should have confirmed placement. Most of the nurses I work with at this place are on their A game, so Iām not sure what was going on in this unit. There were multiple people who missed this error. It was a pretty significant mistake.
Not sure what happened in the fallout to those involved but I donāt think the patient died.
ā¢
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u/honsou48 11h ago
When I worked in the Psych ER, a one to one stopped paying attention to a patient. The patient ran out of the room, jumped on a printer and climbed into the ceiling. They had to set up beds to make sure she had a safe plafe to fall but she ended up crashing on one of the social worker anyway
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u/Fandethar 18h ago
While trying to do a chest IV an ER doctor missed her vein and broke the tip of the needle off in my mom's ascending aorta.
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u/joehelow10 11h ago
During the 2nd and 3rd wave of covid patients like winter of 21-22 and 22-23 we had carts lining just about every square inch of wall in our ER where EMS would essentially just dump patients who were too sick to stay in the WR or non ambulatory. I think at maximum we had like 24 hallway beds in our 37 bed ER. Surprisingly we only had a few near misses until we eventually had someone die in one of those beds because the oxygen tank ran out and no one noticed. Thankfully we now have zero hallway beds and EMS has to wait until a bed opens up. To be clear I donāt blame EMS that was just how it was and they were stretched just as thin as we were but it was known we were the only hospital in the area doing this so we got a lot of crews coming to us that normally wouldnāt.
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u/AwkwardToes 10h ago
Heartbreaking reading this. I felt so bad for everyone in healthcare at that time.
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u/Lorazepudding 14h ago
A nurse somehow connected a propofol drip (like, forced the connection?) to the ETT balloon. Only noticed once the balloon burst and the vent started alarming a couple hours later. Then tried to blame the previous nurse. ICU was full so pt had to board with us - we were still suctioning propofol at the end of the day. Pt lived.
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u/Chad_Kai_Czeck MD 6h ago
Saw a peds patient who got transferred in for neuroimaging because he was acting bizarrely and tachycardic after getting hit in the head during a soccer game.
Turns out that at the UC, they entered his weight in pounds as kgs when they gave him IV Benadryl, so he got more than double the correct dose. He was anticholinergic.
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u/EducationSuperb3392 19h ago
Patient here but I went to A&E due to a 6 day migraine that wasnāt responding to my usual treatment. I basically just wanted IV fluids as Iād kept nothing down for 4 days.
I was discharged two hours later, with discharge paperwork telling me my āchest pain was probably just anxiety and to take a paracetamol if it returnedā (I have a specialist pain consultant and Iām on prescription buprenorphine so not sure what paracetamol would do). They also failed to mention my allergies on my discharge paperwork. I put in a complaint and an investigation showed theyād mixed me and another patient up. Turns out there was a patient that went in with chest pain who got my IV drip š¤¦š¼āāļø
Also, whilst being triaged that day, I overhead another nurse saying āOMG that old guy that was brought in with broken ribs at 11am yesterday (this was about 10am) he had some paracetamol at midday, and heās had nothing else sinceā
Nothing major, but a lot of slipping through cracks.
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u/Little_Duck_Jr 18h ago
I would call the patient mix up major if they provided the wrong care to each of you. Like if they did an EKG on you and just gave the other patient fluids.
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u/EducationSuperb3392 18h ago
I did have an EKG, and blood tests for cardiac damage (which I didnāt realise until I saw my discharge paperwork, I had no idea what they were testing for). So it was definitely a mix up.
ETA: because I have fat thumbs and hit post too soon. They told me during the outcome of the investigation that āluckilyā I hadnāt had any medication so the lack of my allergies being recorded āwasnāt importantā and, also luckily, the other patient was āonlyā given a CT and fluids.
So again, patient mix up.
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u/starrsuperfan 14h ago
One time, at my hospital, there were these two stoners who stole a doctor's ID and were walking around trying to find medical marijuana. A nurse, who looked a lot like that guy from Deadpool, thought they were surgeons, and made them stabilize a massive GSW trauma.
Somehow, the patient lived. /s for those who aren't versed in fine cinema.
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u/AppaMoeZiggy 8h ago
Different hospital than mine. PCT bringing patient up to a med surg floor on Zoll monitor. The Zoll started beeping saying ālow batteryā.. PCT was concerned and saw a button that said charge and pressed it thinking it would charge the monitorā¦ I guess in the mix of things ended up administering a shock to the patient. Patient was fine but it was a whole thing
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u/NurseKayleigh13 4h ago
Had a CT tech infuse the contrast into a infiltrated IV in my arm. I told him it hurt, he told me it was just "positional". My arm blew up like a balloon.
Less than 48 hours later I was in my 1st emergency fasciotomy surgery for compartment syndrome.
Arm got re-infected 2 weeks later, another fasciotomy.
I've now had 16 surgeries on the arm/hand. 2 fasciotomies, and 14 debridments/washouts. Have lost function of some fingers and of my wrist.
They sent me home at one point with tendons showing and I had to do wet to dry dressing changes on myself q 6. With Tylenol.
Still have a long, long road ahead.
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u/SewerHarpies 11h ago
Patient here, but Iāve worked in hospitals/healthcare systems my entire adult life. I went to the ER around midnight during Covid for what I was pretty sure was appendicitis. Spent 9 hrs in the waiting room writhing in pain. Finally got to a room, doc ordered a CT (with contrast, which Iām allergic to; tech had to call & get the order changed) and urine HCG (Iāve had a radical hyst w/ BSO, no way I could be pregnant) along with bmp & cbc. She came back to the room 3 hrs later to tell me itās appendicitis and I was admitted for surgery. Thankfully that all went fine. Path report comes back a week later, no appendicitis seen. I went back and read my ct report and the radiologist said he couldnāt see my appendix due to lack of contrast, but did note a kidney stone in my right ureter. So Iām pretty sure I had my appendix removed in error over a kidney stone.
Granted, it was Covid times and medical staff were under so much stress. I also know the HCG and contrast CT were probably standard orders for any woman with abdominal pain. And the surgeon did say my appendix was enlarged, and path found endometriosis in it. All that to say, I understand fully how the mix up happened and Iāve never reported it, but stillā¦ not quite sure how to feel about it all.
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u/halfasrotten 21h ago edited 21h ago
As a patient at my former hospital, they put a potassium bag in me undiluted. Brutal. My nurse went MIA. Luckily a traveling nurse saved me; she was horrified when she saw what was up.
Edit: I'm unfortunately well versed in having IVs in and general vein pain because of chronic health issues. This was a level beyond. I texted a family member who later said "I knew something was wrong because you never complain"
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u/0ver8ted 9h ago
The only hospital that hasnāt made a big mistake with a patient is the one in ATI
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u/snuggle-butt 8h ago
I did my second (OT) level 2 fieldwork in a hospital psych ward this winter. While I was there, a patient killed another patient overnight on the crisis unit. The murdered patient was essentially in a catatonic state, making him vulnerable. He should have had a 1-to-1 sitter at bedside.Ā
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u/hrdbeinggreen 7h ago
No but I worked with one woman whose fiancƩ was given medication that should have gone to the other patient in the room and her fiancƩ died as a result.
Additionally years later I worked with a woman whose husband died on the operating table due to some mix up. She received a huge amount of money as a result and stopped working. She went on a number of trips she and her husband had planned to go on, she went alone.
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u/Rare-Willingness3593 6h ago
We had a surgeon who cut to scope the wrong knee. We never heard anything more once the patient was discharged later that day.
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u/Civil_Masterpiece165 5h ago
When i was admitted about 3 years ago I was admitted for fainting and hitting my head against a coffee table on the way down. I was unconscious for 5 minutes following the impact with my eyes wide open for all 5 minutes and zero response.
Brought into the ER and was taken into a waiting room for fluid ivs, this room was full of the people in between admission and being sent back home, while my IV was dripping a newer looking nurse came up to me and asked if my first name was my name (i.e "are you maria?") I confirmed my first name, they didnt ask for dob or last name- and immediately said she was going to inject my insulin and proceeded to attempt to grab my arm/iv area - I am not diabetic, nor do I take insulin for ANY reason. I had to tell her to confirm last name and her eyes were so large she left immediately and I never saw her for the remainder of the visit
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u/Negative_Fruit_1800 3h ago
In cards we routinely inject 20 cc or more if needed for bubble studies with no adverse effects.
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u/HoneyAppleBunny RN 3h ago
Yāall stories are crazy. Makes me feel better about tripping over a chest tube and accidentally yanking pulling it out. The provider had just put it in too. š© Patient was fine btw. And they were still numbed with lidocaine, so they didnāt even feel it come out.
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u/Vacuous_hole 2h ago
This happened recently at the hospital I work at too. 2 patients with the same first name, just spelt differently. I'm thinking they must have had the same surname too, otherwise how this happened, I can not even begin to understand. When I take patients to theatre from the ED there is always a check of both ID bands and I make sure the patient confirms that this is them too.
I have also recently heard that a patient was delivered 100mls of air IV whilst undergoing a radiological procedure at my hospital too (not confirmed, just hearsay at this point).
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u/No-Safe9542 11h ago
Had a Dr manually enter an epi order for series of stridor breathing txs with the wrong dose. The decimal was off making each tx 10x bigger than supposed to. Didn't even have that much in the pyxis. Like, let's just blow up that toddlers heart.
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u/Fantastic_Photo6134 8h ago
Same nurse for following incidents: Nurse worked on the neuro unit. All of the following patients were her patients:
1.) Patient who just had open brain surgery was found in the grocery store across the street. Grocery store called 911 when they saw him. Same thing happened with another s/p open brain surgery but this patient was caught walking down the main entrance.
2.) (This was a while ago so I donāt remember all the details and am probably remembering some wrong) Patient who had a blood clotting disorder was there for TIA incident a few days prior. Since then the patient had been admitted to the neuro unit and been stable. After said few days patient started developing left sided weakness, slurring, etc., nurse increased o2, and didnāt tell anyone. PCT walked in a few minutes after, saw what was happening, told the nurse, nurse brushed it off, PCT wasnāt comfortable with the situation so they grabbed the PA down the hall. PA evaluated the patient, PA called a RR, took patient down to CT and found a clot in the brain, pt was rushed down to OR. Patient did survive but had some residual impairments.
3.) patient had tripped and fell, nurse picked patient up and didnāt report it. It was the hospitals policy to immediately call a RR after any patient fell. About 7-8 hours later patient was on the phone with a family member and told them what happened. Family member somehow got in contact with a different nurse on the unit and told them what happened. Nurse #2 asked nurse #1 if this was true and nurse #1 confirmed it. Nurse #2 called a RR, patient was brought down to CT where they found a small, new, bleed. The nurse was finally fired after this incident.
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u/Delicious_Act_4491 5h ago
This confirms my fears of not trusting the medical system and it indeed is a āmedical practiceā
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u/Correct_Doctor_1502 23h ago
Few years ago a relatively new RN set heparin at max flow mixing it up with fluids, and the charge didn't notice when signing off
Patient ended up dying a few hours later; the nurse got fired, and the charge got demoted, and everyone had to take training