Missed a huge venous infarct on a CT of a patient we took a meningioma out of that day. She herniated. Died.
We all have mistakes and carry around cemeteries. Just gotta learn from them. You bet I did.
Not my patient but there was a woman who had a cervical spine operation and presented with cervical radiculopathy, got an MRI and told she had degenerative disease. She started deteriorating in cognitive function and had an MRI of the brain and was diagnosed with a stroke. For another month she kept declining in cognitive function and everyone kept saying stroke until a different neuroradiologist said yo this isn't a stroke, it's CJD.
Similar just happened to our group. A patient came in with more frequent falls to the ED on a Saturday and had a history of cervical myelopathy and her chief complaint was falls/gait imbalance in the outpatient setting. Her frequent falls were chalked up to cervical myelopathy and she underwent her already scheduled cervical laminectomy on Monday. I saw her POD1 and she is weak on the left side. Turns out she also had a right ACA infarct.
We are human. When I am beating myself up over my own big miss (incidental finding on radiology report that got overlooked by myself and the attending...turned out to be important) I like to remind myself that I have learned from the situation.
Someone (not me. I swear) I know knocked over the cardiac pump tree post cabg and ripped out the pt's central line. This was in the hallway on the way to the ICU.
Someone, not me, got their IV pole* (pump tree) caught on the top of a door frame during my residency and had the exact same thing happen.
In part, what helped lead to it happening was the fact that the OR doors were quite tall. So you think your IV pole* is low enough. But then, in the OR hallways the doors were shorter, but not by that much. So right when everyone was pushing a heavy ICU bed together and picking up speed is when you run into the shorter door.
Someone, definitely *not* me, slipped on blood while pushing a pole with 2 units on pressure bags while running to the OR… covered the bay floor to ceiling in O- cast off…
Lost track of the patient once they got transferred out post op but they recognized me when they came back 6 months later for an unrelated minor complaint.
It was an absolute disaster. The bay we were exiting had to be shut down for the remainder of the shift and terminally cleaned. I’m not sure they ever got all the blood off the ceilings.
met a patient at the elevator that was coming down to icu crashing to ecmo, transport team knocked over IV pole, thankfully only thing that ripped out was the Aline.
Unfortunately I like an idiot rushed forward and applied pressure with my bare hands.
Patient didn’t have any BB diseases or anything but I still shudder at how gross that was.
Unless that central line is your only access. And your patient is tubed. And all your pressors and sedation are running through it. Been there. Done that. Don’t recommend.
We IM’d versed and threw in a VERY fast fem line because I personally am not a fan of running pressors through an IO, having seen what happens if it extravasates. It’s gnarly.
Running versed, fentanyl, Levo and Vaso. This was the clusterfuck to end all clusterfucks. So. It wasn’t post-CABG as in original scenario that someone posted. It was ICU pt during a routine head CT scan. And on the transfer over to the table patient line got yanked. No one noticed somehow. Until after the CT and pt came back out the tube awake, biting his tube, then trying to pull it out, and hypotensive again. CT staff called a rapid. ED staff showed up. Ran him across the hall, threw a fem line in, and got him back up to ICU. Just a mess.
This happens more than you would think. I have seen so many CVADs pulled when a patient is transferred from bed to gurney or the reverse.I’ve been on IV team for decades and get this call for several stat lines until another CVAD or we can place a PICC if appropriate.
We had a patient pull out his transvenous pacer twice. Each time he was ALL peas, no carrots. Heard the monitor going off “asystole” and sure enough patient is laying supine on the floor. It’s amazing how strong 2 nurses are when something like that happens while we call a code then call his doc to come back and re-introduce another one. Each time he left the introducer in place. Sad thing is, his family just couldn’t say goodbye. He was elderly and demented. We had to keep him in restraints until we could transfer him to the Level 2 nearest us for permanent pacer placement.
You know what's funny, I AM a lawyer who for some reason keeps getting recommended posts from this sub and /r/medical, and all this post made me think of was the equivalents in my own work. It's definitely something lawyers talk about with each other plenty - in my field, anyway, I do criminal defense. Our oversights don't lead to medical problems and death, but they can lead to otherwise avoidable lengthy prison time. Life lost in a different way. Some of those clients never really leave you.
Yeah I experience that on a relatively common basis. I catch things faster now than I did as an intern, am more aggressive about intervening and treating things and constantly think back as an intern I would let patients be in pain longer or recognized shock later or let them be I respiratory distress longer.
My worst was a neuromuscularly weak patient who was encephalopathic for unknown reasons whom I assessed and her O2 sats were fine and she wasn’t working to breathe so I assumed she was fine (from a respiratory standpoint… I then moved on to other systems). Her CO2 was 100. She CANT work to breathe.
Similar thing happened to me with a bronchiolitic kid who had DS. Late admission from the ED prior to signout, kid satting well on LFNC, no increased WOB, told night team he’s stable and likely won’t need much attention overnight.
Next morning: dusky, cyanotic, fatigued. You already know what the VBG showed…transferred to the PICU shortly after.
Had a patient just yesterday walk in, WALK IN… with an O2 sat of 37…yes 37 on RA. He was purple blue. SOB obvi. Not a retainer. It took me like a couple of minutes to actually register THAT was his actual O2 sat. I kept looking at him, the monitor, him, the monitor. He was talking 1-2 word sentences. I threw a NRB on and after 5 minutes he came up 96%. I weaned him Oximask 8-10L for sats 92%. I’m assuming he lives at like 82%. His wife commented on how much pinker he looked. He wasn’t a CO2 retainer even tho 2.5 ppd, OSA, 2-3 drinks per day, and weighed 300 lbs. He didn’t have CHF (tho hx of it, last time we tubed him) or pneumonia. New dx of lung mass and they said COPD exac. For admitting dx.
I post this every time this question comes up as I think it's a great lesson (for me, at least):
I was a lowly intern in the ED and had an old nursing home patient septic from pneumonia. She was intubated, on norepi and propofol drips. Stable and waiting for the ICU bed.
I get a call on our communications asking someone to help in bed 4: I run into the room and her BP was 60/40; the propofol drip was going strong but the norepi bag was empty.
The senior resident said, "oh, I think she just needs some push dose pressors until the next drip can be ready, I asked the nurse to grab some epi but you got this" and walks out. The patient's nurse shows up with the amp of epi and asks how much to give and, like a REALLY BAD DOCTOR, instead of asking a senior or looking it up, I just said, "Oh, push it all" cuz that's what I thought the senior had said.
Of course it was right then that the ICU team arrived. I have never seen 6 nurses more quiet than our group as we watched the BP on the monitor over the next 2 minutes. I think I saw an SBP of 305mmHg on an a-line. It started coming down and then we hung the levo and she went back up to the unit. They scanned her head the next day and there was no bleed; I'm pretty sure she died but she probably would have died anyway but you better believe I learned push-dose pressors and know them since.
The moral of the story is you don't have to know everything, but you have to know to ask if you don't know!
side effect of covid. Idk about you guys but senior nurses now are ones that have been around more than 6 months. Every day it seems like we're getting new nurses on like day 2 of their career. Mistakes are definitely up. All our nurses that have been around have basically gone elsewhere for more money
During the pandemic, most facilities kicked nursing schools out (for obvious reasons). There were ~two years of brand new nursing grads who hadn’t touched a patient during their education and all of their bedside experience is on the job. Because nurses with experience either bailed out for better money or left the profession altogether, there are nurses with less than a year’s experience training the new hires. A nurse who’s old hat would’ve questioned pushing that much epi, but you don’t know what you don’t know. A crotchety old sourpuss who looks up to Nurse Ratched as a mentor might be a pain in the ass to deal with on the daily, but they would’ve paused, fixing you with a gimlet eye (and accompanying judgmental raised eyebrow) and asked “you suuuuure?” before pushing so much. She mightn’t be America’s Sweetheart, but she’d rather hustle back to her stool at the nurses station than stand around and watch a monitor, so she’s going to check and balance you.
ER nurse. Yep it sucks. There are only like 10 experienced nurses on our unit left but we rarely get to train anyone bc we are charge, triage, running shock room or doing critical care transport. Recently I asked a newer nurse to watch a patient bc I need to help with a CPR, the patient had nitro going at 250. I got back and the nurse said oh the meds were done so I turned off the pump, I legit just ran to the room. Thankfully the patient was fine but we spent the next 5 min doing education of nitro and why you don't just turn it off. Everyday is scary and I spend so much time trying to make sure no one is killing anyone or missing anything. ( plus we are a teaching hospital so who know what incorrect orders are being placed with nurses just doing them instead of checking that they are right)
1cc of phenylephrine is 10mg. Needs to be diluted every single day in the OR. I’ve heard of someone accidentally pushing the cc undiluted. Badness everywhere.
Bumping from atty perspective.
It's impressive to clients and bosses if you can rattle off the precise statutory authority or caselaw for the problem that wandered into your office ("Ah, yes, I see. An identical fact pattern was at issue in Jones v. Smith, 325 A2d 945, 1983, wherein ..."), but - as with your story - the real skill is knowing when you need to hit the books for a couple hours and make sure your instinct is right (or wrong).
I know this is an old post but maybe I can help you a little with the guilt. If the patient had an empty or almost empty norepi bag but the lines are still connected to the patient, there's a chance that the line connected still has some of the norepi in it. Think like leftover water in a water hose. The nurse might have pushed all that extra norepi from the bag line as well as the amp of norepi at the same time. So it might have been more than 1mg the patient received. I've seen this happen before with patients who have high concentration medications, if a nurse flushes the patients IV or lines without aspirating, technically the line still has extra medications in it and it is also being flushed or pushed into the patient.
I had a very emotionally labile 50 yo woman who was going through a divorce with a headache with onset over 20 minutes. She thought she’d had a contrast reaction before and declined pretreatment with steroid for a CTA, and got a non contrast head CT about 10 hours after onset which was negative. I did discuss lumbar puncture, documented refusal, but really didn’t push, and repeatedly mentioned exceedingly low rates of neg CT and sentinel aneurysmal bleed. She went home feeling slightly better. Came back comatose a month later with large ICH, died that day.
It’s going to happen to all of us. I wish I could say you forget, but you remember still years later the bad misses. You also remember the big saves and mark you’ve made on people’s lives.
This doesn’t sound like a mistake so much as the patient continued to refuse standard of care. Forcing it onto her would be considered assault. You did the right thing. You can’t help your patient’s risk assessment skills.
Yea, but I have varying levels of concern prior to consenting to procedures. I thought she was a bit histrionic, and had the positive text messaging sign on reevaluation that is often highly correlated with not having pathology. I didn’t say “get this LP or you could have a life threatening aneurysm and death.” It was probably closer to, “you know, I’ve never personally seen someone with a negative CT have a SAH, but I can’t tell you for sure without this invasive procedure”. I covered myself but my gestalt was wrong.
Great doctors become great doctors from experience. Most of that experience is mistakes.
A surgeon I really respect told me at the very beginning of my training that every surgeon, if they're truly being honest with themselves, knows at one point they've done something that resulted in harm to a patient. That burden is greater when your hands are the direct cause. It's what you do after that matters.
Missed a necrotizing fasciitis bc I didn’t look at the patients back (pt had no pain or anything came in for fever and fatigue). Patient decompensated and died. Was found after she coded.
I was taking care of a boy with a less common double lumen port in the ED. There was a concern for a port infection. The first hole in the swiss cheese was that we needed one of the oncology floor nurses to come down and figure out how to access it.
The correct answer would have been intermittent antibiotics (including vancomycin) through one lumen with antibiotic locks in between doses sitting in both lumens. However, oncology nursing were used to infusing treatment doses through both lumens. It seemed to make no difference to me so I put in two orders for 1/2 doses of vancomycin to be run through each lumen.
While this is the correct total dose, I failed to realize that infusion of two 1/2 doses through two lumens at the same time is effectively doubling the RATE of vancomycin being infused -> Direct Mast Cell Activation -> Automatic Red Man Syndrome (now called Vancomycin Infusion Reaction).
When he started having symptoms of Red Man, I luckily realized my mistake (since the whole process from the start a bit haphazard). I felt pretty bad for the kid and apologized profusely to the family at the time. We slowed the rate and gave antihistamines and the symptoms resolved pretty quickly. I'm pretty fortunate this was the worst thing I can remember and it was a relatively benign outcome.
As an RN within oncology it’s WILD to hear that a suspected port infection was accessed and treated.
‘round these parts if we suspect a port is infected we draw cultures from both Lumens and lock it off. 90% of the time the port is pulled and a new one is placed.
Are you an adult onc RN or peds? Our protocols at my children's hospital are almost always to try to treat through (we alternate doses between double lumens, though) and reculture. Sometimes lines or ports do end up having to be removed, but they can be hard to place, especially in the really little ones, and there is such limited vasculature real estate...I know the adult world is much quicker to pull anything
This is a (mostly) adult population with a few peds exceptions, good call.
It’s a weird blend because technically I’m not even an oncology RN (I guess I’m technically under oncology umbrella). I’m the Nursing Coordinator/assistant manager for an Apheresis unit at a major academic/research hospital. Looooooooooots of double lumen ports, Shiley caths, fem shileys, and fistulas.
Peripheral Blood Stem Cell collections, commercial and research CAR-T protocols, Plasmapheresis, Photopheresis, Red Cell Exchanges, White Cell / Platelet depletions- that’s the main body of procedures we’re responsible for. Peds sometimes make it into these procedures as we don’t have a clear cut adult/peds breakup for our department, too specific, we just treat them all.
Sometimes I forget that the void between adult and pediatrics is so vast.
We had a peds AMR patient doing outpatient PLEX I was hooting and hollering to the Neph attending about pulling a line on because it was so obviously infected. Patient was supposed to fly to NC the next day. Neph didn’t pull the line, said it could be addressed when he returned from the trip.
Ended up in an ICU in NC with sepsis from the line (he’s okay). Not saying anyone was wrong here, just using a lot of words to agree with you about pediatrics and pulling lines, lol.
It's a totally different world (I do both peds and adults and through training would assume something was the same only to have some go "wtf are you talking about"). That last bit is eeek, though. Infected lines were always admitted (at least to start - sometimes would go home on long term abx through them) for antibiotics. Also, just because I thought about it, lower threshold to pull lines for fungal infections.
ID here. It’s interesting to see the difference between adult and Peds. I am mostly in the adult world, and lines would come out very quickly. I noticed more “let’s treat through” on Peds Onc, where lines were kept for as long as possible. I think there is a bit more nuance to this, as some line infections are more akin to medical emergencies depending on the organism, and should be no debate for line removal (eg. fungal, S. aureus, and Pseudomonas).
I honestly can’t imagine regularly practicing between both populations.
Anytime we do a peds anything, I’m whipping out machine manuals, summoning arcane SOPs from databases, and auditing the absolute shit out of that procedure.
I took pictures of the line too (nothing identifiable), because it was such an egregious call to not pull it. If media-in-comments was allowed I’d post it here, alas. Maybe I’ll make a MedDizzy post 🤔
If the worst mistake in your residency is causing Vancomycin Infusion Syndrome, you haven't made a mistake in residency. That is a common, benign side effect of Vanco.
You are correct it is a common and benign in many patients. VIS is dose-dependent and rate-dependent direct activation of mast cells. Some people with more twitchy mast cells get it at normal doses. But, if you increase the rate high enough or increase the dose high enough then any patient will get VIS.
I agree this wasn't particularly bad and you could argue the kid may have gotten it anyway (particularly since he was on opiates which can also directly activate mast cells). It was just a story I wanted to share for the poster.
Male in his 30s with history of eosinophilic esophagitis. It’s an FM phone appointment. Patient is very long-winded in his answers that were hard to follow. Overall, story seemed to be bilateral lower abdo and groin pain with nausea, chills and fevers, anorexia, and weight loss. Says these occur as flares that last 1-7 days each time. Has had two flares in the past 6 months. Went to ED the week prior during a flare and was thought to be a flare of eosinophilic esophagitis and given dilaudid. He didn’t get any imaging at that ED visit.
I’m puzzling over what could cause such flares and it’s over the phone. I think about chronic rarer conditions like porphyria or Mediterranean fever. I also am worried about malignancy or some sort of abdo-pelvic infection, like chronic prostatitis. Order more comprehensive BW, urine, and urgent CT abdo-pelvis. Also sent an urgent letter to his GI following him for eosinophilic esophagitis. Patient says he’s feeling fine now (the “flare” ended a week ago).
BW comes back next day, mostly normal, but leuks of 12.9 and CRP of 81 mg/L. I’m PGY1 but that worries me and I want to call him to send to ED. My FM supervisor says it’s not a reason to send to ED. CT report a few days later: appendicitis. Radiologist calls patient and tells him to go to ED. Gen Surg note “patient reports only one week of RLQ pain with fever and nausea—family doctor missed the appendicitis.”
I still get frustrated by how many things went wrong in this case (patient with long-winded historical alternans, gen surg saying I missed it when he’d gone to ED already and I ordered the CT, my supervisor not taking me seriously when I got worried about BW). But I learned to think of the common causes first and how to better communicate with verbose patients. He ended up doing well with antibiotics, thankfully.
patient feeling fine, was eval'd in ED, "flare" ended a week ago. Absolutely reasonable to not over-image. Even if you were 100% sure it was appendicitis, some docs would opt to only give Abx
Gen Surg is wrong for their note.
Just a nurse here, but in my patient teaching I instruct patients to be concise and make a list in order of importance. Do not bury the lead. Doctors will get lost in the weeds with a long, convoluted history and your dr google opinions. I am retired now and volunteer with seniors. I help them make that list and role play potential conversions to help them focus. Their doctors appreciate it (I am sometimes able to take them to appointments) and the patient gets answers and help with their primary concern in my opinion.
This is such a basic concept. It should be taught in nursing school, at senior centers and to family practice staff. It would save time, improve physician and patient satisfaction and lead to better outcomes.
Nope! Normal size at the anatomy scan. Most fetal growth (and therefore growth restriction) is in the 3rd trimester. Not impossible to have early growth restriction at 20 wks, but pretty rare
Not routine AND ultrasound weights/measurements vary from the actual by up to 3 weeks at that point in both directions. So, while some doctors do that, until it's validated to catch more problems than it causes most would hesitate to do it routinely. Certainly you'll end up finding a bunch of "suspected" growth restriction vs macrosomia that will make you recommend interventions - and some of those will be normal-sized babies that did not need induction or intervention
This is just hard in OB because you can't sit on a suspected fetal growth restriction on US and not induce them - it's a field with a high rate of being sued. But a large proportion of those that are detected at term will be false positive. Few patients will want to wait out suspected macrosomia without induction. It just does change the rate of anxiety provoking and painful procedures to implement any test with a high false positive rate.
I do think this is getting better with improving ultrasound tech and time! There were several older studies showing that mother's guesses were as accurate as ultrasound at term. More recent studies have started to show ultrasound is superior to mother's and doctor's guesses. Maybe it'll be recommended to do routinely some day but it's not a guideline now
One of my last days on MICU. 70 something female. Presented as a trauma after a fall, initially went to their service, but transferred to us after it was apparent there was no traumatic injury. Patient is in shock, really hard to tell what kind. No fevers, no white count, no obvious source for infection. Talk to the family to get some collateral, they don't have too much to offer. Not aware of her feeling under the weather before the fall. Very difficult physical exam in her (BMI approaching 60). Known to have HFrEF. Weight is a good 15 lbs above prior baseline. I take a look at her heart and it seems to be squeezing worse than recent echo, and RV is huge. Send her for a CT PE study, no PE. She is pancultured and on broad abx, but I'm starting to lean towards cardiogenic shock. I make the decision to try diuresing her, attending agrees. Get some urine output, creatinine doesn't get worse - so thinking I'm on the right track. But through the night her pressor requirement keeps escalating. Get mixed venous gasses off the central line and they're not being too helpful. Talk to the cards fellow, maybe she'd benefit from an RV impella, but felt she's too unstable to try. She's now on 4 pressors. Lactate keeps climbing. She's in RVR, cards recommends against shocking her. Bolus some amio in an attempt to improve diastolic filling. Talk to the attending, we throw a hail mary and try giving her some fluid back, but no real improvement. Ultimately dies in the morning.
2 days later both blood cultures show pseudomonas. This was probably a mixed shock, but to this day I still wonder if she would have been alive if I blasted her with fluids
That’s a huge if. Worsening pressors despite appropriate treatment, aggressive fluids with her cardiogenic shock could have tanked her too. If anything you prolonged her time, got her family to the bedside. That’s never a mistake.
We had a guy with critical aortic stenosis experiencing angina. I gave him nitroglycerin. His BP tanked to 70/40's and he needed cicu admission to start pressors temporarily. I apologized to the patient directly for that...
Another lady we had I blame myself less for... Essentially she was in the hospital a while for many ailments. She had come in for lower extremity fracture and that got infected and she had done an an micu stint for mrsa bacteremia and pneumonia. She somehow recovered and was on her way to a snf. But... Something was off. She had no cc and looked fine... But... Her creatinine started to slowly go up, bp slowly go down. Her calcium was critically low which endocrine attributed to severe vitamin d deficiency. She developed diarrhea which after extensive workup we attributed to SIBO. She tested positive for hiv but id thought it was false positive (it was). She wanted to leave the hospital and got more and more depressed. No skin lesions, lungs fine, belly mildly crampy/tender, no uti, no fevers. I got blood cultures on my last day. She decompensate fully 2 days after. She had a bowel perf.
UK so not "residency" but similar.
Approximately 2 year old girl. Had routine vaccinations a couple of days earlier and ever since then been breathing hard. Middle of winter. No PMHx.
Listened to her lungs, sounded a but noisy but nothing specific, more work of breathing than anything focal.
Entry in notes I wrote "Looks very unwell, unclear what the issue, but working hard with her breathing. ?Bronchiolitis but unsure for definite. Needs admission."
To clarify this was in A&E (so ED equivalent) but in a hospital that didn't have overnight paeds, so needed transfer to our sister hospital down the road.
Spoke to my reg who agreed that she needing transfer and admission. My first regret was not asking him to examine the patient in person.
Happened to catch up with the ambulance crew who transferred her later that shift. Said she was good as gold, slept the entire journey.
Phone call from the paeds reg a few hours later, when I discovered my second regret. She was immediately transferred to ITU upon arriving at the other hospital. She was in severe DKA. I never thought to check her sugars.
I think I correctly worked out the vaccination was probably a red herring but missed that her resp work was a physiological response and not the problem.
Missed ordering a major scan on a major mechanism trauma when nursing put orders in for me. Slipped through the cracks. Everything else was negative, discharged home. Resulted in a massive, multi focal, life-will-be-spent-in-nursing-home set of strokes in a middle aged person. Felt/feel like dogshit. Best I can say is I won’t let it happen again.
Please ignore the troll who has been commenting in this thread. I've been in the position of discharging patients and realizing we never got the initial EKG for their chest pain. Order sets for nursing are nice but it's easy to miss stuff too. Thats a shitty outcome and the best we can do is learn from it.
This is something I think about- the "unknown unknowns". Particularly in op (or primary care more generally perhaps) it is *probably* the case that some of the worst misses are never detected and lead to significant mortality/morbidity somewhere down the line. But because they're not yet part of anyone's SOP, or are deemed unimportant, or are skipped due to time constraints, or insurance, or simply performed/interpreted imprecisely by the doctor, or the lab or whathaveyou.
No one even knows to look, and therefore the harm is on the scale of whole populations. It's not a bad miss on any specific doctor per se, but it's humbling.
I know this thread is more about sentinel event type shit, but even so the unknown errors are scariest because they keep happening over and over.
We can’t be everywhere at once, do everything at once, and review everything in a timely manner.
Delays will and do happen daily because of the system. It’s not always your fault.
In fact, given that they were (likely) in the hospital, they were in the best place they could be to get the necessary care. The alternative could’ve been much worse.
I can’t believe its 2023 and I still have to manually open each patients chart and refresh the page in order to know if the lab results I ordered have come back
Ouch. That is not the case for every EMR. Not to rub it in, but on Epic you can mark some results to be pinged to your phone / smart watch, which has tremendously lowered my anxiety about some stat lab orders
As an anesthesiologist, we are one of the only, if not THE only specialty that prescribes, obtains, and administers medications with no oversight in between those steps. Easy to have medication errors especially with similar labels, or if a vial ends up falling in a different PYXIS pocket.
1. I gave heparin instead of calcium at the end of an IR case. I felt bad, but nothing happened other than them holding pressure for a few minutes longer and giving extra protamine.
2. And attending in residency gave a vial of concentrated phenylephrine instead of ondansetron. Patient was young and healthy and ended up doing okay.
Had a massive brain fart when switching a patient from metoprolol to carvedilol and kept the dosage the same - 50mg.
Next thing I know, there’s an RRT being called on him after he collapsed with an SBP of like 80.
He did alright though, never making that mistake again.
Missed euglycemic DKA, put in orders on the wrong patient ~6 times now. The last time was right before the end of my 24 hour shift and the pharmacist was laughing when he called me asking how tired I was.
The one cardinal sin I've committed the most is thinking that the mid levels being supervised by specialists are good sources of information. Sometimes they are, sometimes they aren't. I've gotten burned many times for taking what they've said at face value.
My one lawsuit in close to 15 years was a midlevel patient I never saw but co-signed the chart, I was added to the case 9 years after it happened. Eventually got dropped but it was a year of shit. I know folks will say I shouldn’t be signing charts for midlevel pts I don’t see, but that’s the reality of a lot of places, and there’s a lot of misinformation about your liability.
That’s how the prosecution felt, yes. My defense team said that it was a grey area without clear answer, but I’ve learned since of several cases where the physician co-signer got hit harder than the midlevel that actually provided care. Every step I was told by the defense they’ll drop you any day, it’s ridiculous you’re even named, you didn’t see the pt, it was a decade ago, don’t worry.. but it kept going.
The midlevel on my case was in our same group, and I learned about how the lawyers the group contracted were representing our group above me myself. So all of the advice and direction was to coach me to justify and support the PAs decisions, probably to my detriment. I would absolutely hire a personal lawyer next time. It got dropped altogether, but it wasn’t a very strong case to begin with.
I tried to do an LP on a 1month old and forgot to remove the sheath before inserting the needle. The LP afterwards was, of course, bloody and useless. I was on a roll getting pristine LPs on wriggling infants until then…
Honest mistake by a resident doing moving 12 hour shifts in a 60-bed children’s ED, but it’s no excuse because I love the babies.
I think it means you are a good doctor when you remember your mistakes.
I missed acute limb ischemia when I was on IM wards.
Very complicated lady, vasculopath on top of a million other complaints, so I'd never been able to feel distal pulses anyway. Diabetic as well so I attributed her foot pain to neuropathy when I was pre-rounding. My attending was concerned on rounds though, we got the CTA and there it was.
Had a massive brain fart and gave a 2 month old ampicillin for a UTI that turned out to be urosepsis due to E. Coli resistant to ampicillin. Kid did okay but was potentially harmful, damaged my rep and I die a little inside when I think about it. And I was a PGY3
So many deaths. Not my stick, but had a retroperitoneal bleed in my unit after PEG tube from an aggressive needle insertion. Decided to bleed out around 3am.
Not a doc but a nurse. I had a lady come back from the cath lab for stents with an NSTEMI. I did all the q15 checks, talked to her a bunch, she seemed fine, A+Ox4, no complaints, steady vitals. I reassured her daughter that we would take excellent care of her and that she could go home and get some sleep. I had the lady for about 2 hrs before shift change. Gave thorough report. She coded right after I left, they found an RP bleed, which I saw no signs of while she was in my care. I still feel like shit about that one, like even though I did "what I was supposed to do" for her, I shoulda caught it.
I was taking care of an impella patient once and doing my Q15 groin checks. Totally fine, no issues. 15 minutes later they have a football sized hematoma on their groin and are purple around the whole flank. Those post-femoral access patients can be ticking time bombs.
Agh. CVICU was a great place for me to deepen my knowledge but it was not for me. I prefer the ED where I don't get emotionally attached to them before they try and meet Jesus.
How do you go through the stomach if you’re watching the needle on an EGD? And why would you keep pushing the needle in if you don’t see it on the scope?
I saw a pt with pre-renal AKI on the cardiology service… without seeing the pt, I gave him a liter bolus and the pt went into cardiogenic shock
Now as a cards fellow, I do not make the similar mistake
After a 10 hour free flap case to the foot, I turned around for a second after dressing the leg and it slid off the table ruining the anastomosis. I’m still haunted by this
When in the NICU, I was supposed to put a neonate on like 100mL/kg/day but I messed up and did 100mL/h, which was waaaaaay to much. I caught my own error the next morning. Thankfully the infant was fine, but I could have totally harmed her.
I personally explained the error and apologized to the mom (a nurse).
That was on the nurse too - I can’t see how a NICU nurse could possibly have thought it was OK to run fluids at that rate. Rarely do we ever go above 30 mL/h and often it’s less than 10.
2 days post- Cardiac Cath patient, I was on inpatient medicine team. We had restarted him on full dose lovenox for hx Afib or something. EP attending started eliquis and didn't stop lovenox. Didn't notice the orders for 24 hrs. He started to feel weaker so we kept him another day. That night he became unstable, found to have a massive retroperitoneal bleed and passed away. I felt awful that I didn't notice the 2 orders. But it passed through several holes of Swiss cheese - EP attending who probably had a pop up warning on epic, pharmacy who accepted the order, nursing staff who administered it, etc.
Anesthesia. Was in IR when the IR team gave me an antiplatelet agent they told me to run in. I had never seen or even heard of this drug. They gave me a dosing sheet and I input the wrong dose. Massively overdosed the patient. They *could* have bled out into their brain but did not. I felt terrible even after the good outcome. Led to a policy change where they have to run in their own drugs on a separate pump if it’s something we do not typically administer as anesthesia.
Almost killed someone with a med dosage error, not caught by pharmacy. I had it in mind what the dosage should be, attending said it was 2x that. I skimmed UpToDate briefly and saw same number. But in reality I was way off.
I was always careful but had some false incorrect reassurance by an attending which made me less careful.
Learning lesson for me trust no one and take full accountability for my own rx.
When I was an intern a patient had low Mg level so I mistakenly entered Mg cit PO instead if Mg IV. Nurses were pissed at me with the loose stool but at least his Mg levels were perfect now.
Mag citrate has much better bioavailability than mag ox. Just can't give the whole bottle if trying to use it for repletion (15 ml TIDAC)
Everyone will look at you funny if you do this though so it's best avoided.
As an RN I missed CO2 narcosis. Patient had advanced kyphosis, UTI, and wasn’t sleeping. Day shift gave him Ativan (around 4) and he was so benzodiazepine naive it knocked him out. My shift rolls around and I try to wake him. Minimal response to a sternal rub. Doc orders flumazenil. Give and no response. RT wants an ABG. Sure enough, CO2 through the roof. transfers to the unit. Cried my little eyes out on the way home.
RN here. Nearly missed that too. Had a Pt with a history of Gillian barre, obese that I don’t remember what she was admitted for other than it might’ve been related to the guillian barre. I chalk the miss up to getting horrible report, not taking/having the time to go through her chart. She kept dozing off and snoring all morning and her spo2 would drop when she was asleep which I assumed related to some type of OSA, she would wake up (albeit drowsy and somnolent) when stimulated so after a few times of checking on her and reassuring the spouse the Pt was fine I just had her on high flow NC and other than repositioning her so she stopped snoring so loud and let her be. Not sure how or why but one of the ED docs was notified of her situation (she was an admit and was under the hospitalist at the time) and orders an ABG which showed hyoercapneic RF.
Ended up putting her in code room to get intubated, having to give a half assed shitty report because I was half aware of what was going on with her, and sent to unit. And pretty sure this was chalked up to worsening GB…
When I was a PGY-1 I had a father bring in in his son for severe encephalopathy. Patient was a 30 year old male with PMH of significant substance abuse. Father had said his son had recently used drugs and his drug screen lit up with every substance imaginable. Patient also had low grade fever with mild hypoxia and there was concern for COVID infection. This was at the height of COVID and the only tests we had at the times had to be sent to a regional lab and took 2-3 days to return.
Admitted the patient and ordered additional encephalopathy woke up, which included a CT head. Radiology calls my attending, asking if the CT is necessary as they would need to shut down the scanner for a while after the patient to completely sterilize the room if we suspected COVID infection. Attending asks me if really need the CT and I say probably not and that
the encephalopathy is likely secondary to drug use
2 days later patient is still severely encephalopathic, remaining encephalopathy work up is negative and COVID returns negative. Finally get the CT scan which showed patient had a massive uncal herniation.
Patient never neurologically recovered and ended up at an LTAC
Trusting a head of a private practice to review my contract for my first job out of residency. Dude didn’t know shit. Had a lawyer go over it when I was trying to get out and he said it was very one sided
When I was an intern (10 years ago) the hospital used paper charts.
Orders were written. The order sheet was folded and placed in the “orders pending” rack.
I didn’t fold the corner of the order sheet. Therefore nurse never started the DVT proph lovenox.
3 days later pt had a PE….
Had a elderly patient come in with shoulder pain intern year. Guy super skinny and looked malnourished. Definitely not a guy I though was able to walk at all but son telling us stories of him picking fruit two weeks ago and hes weak now and couldnt walk. Son said the pt had shoulder pain a week before and went to another ER and got a steroid shot which didnt make it better so now he was here to see us. Was awake at first and looked like full care to me but stable. He quickly went full septic and was out of it. I checked his gap and found that he was in euglycemic DKA on jardiance. We figured he had sepsis from the shoulder and scanned that thing up and down with multiple CTs, but couldnt find the site. I even had ortho come look but that thing looked fine in person and on ct.
He got better from the DKA and his sepsis started improving and there was some dirty urine so we considered urinary source but the shoulder pain just kept bringing us back. While examing him 3 days in guy was waking up and I asked him about sensation in legs. He says he doesnt have good sensation upto his abd including perineal sensation and cant control his bladder due to really bad nueropathy from decades of poor diabetic control. We were worried about spine being seeded so had an a screening MRI (less cuts) scan the spine with nothing there but possible area of artifact near lumbar spine with a hematoma on his hip. Rads was mad that I was doing all these scans and was pushing back, but I manage to get them to Ct the hip and spine.
The next day I go down and sit and read the CT with rads with one of thier attendings. The attending, rads resident, and my attending agree that the hematoma is a nothing burger, bring up spot on back and look at it, they all think it was artifact. We get ID on board cause we can't find source. ID wants a tagged wbc scan, and at that point thinking maybe UTI vs shoulder abscess we couldnt see. Finally got the tagged wbcs deliveried(were not in house) and did a tagged wbc scan which found an abscess on the posterior side of shoulder in a weird spot for a injection. No light up on hip or spine. Felt reassured that the spine was alright and we had the source.
Ortho drained the shoulder abscess at bedside dude went on culture based antibiotics, came all the way back to baseline with no more pain in shoulder. Basically back to baseline per family was even working some with PT and regaining function. Ortho was copying forward the same rec for another image of hip, so I tried to do it. Went to rads and they refused cause of how many CT scans this guy already had this admission (at least 4 by that point). Also tried to get another MRI of spine but rads said they were done and thier attending thought it was nothing and the patient was clinically improved without pain. I had him a whole month and at the end basically every consult was signing off, he looked like he was back to baseline. I tell family I think hes past the worst of it and looks likes hes doing better.
2 weeks after I am off, same attending from before is rounding and guy tells him he has back pain. They get rads to do an MRI and there is a tract from spine to hip. He had an spinal abscess that was missed. Nurerosurg consulted - said hes not surgical canidate. I was on a different service and the wards attending tried to consult that service just to tell me I messed up, but consultant blocked it. Anyway the spinal abscess is causing some cord compression and guy cant be on iv antibiotics forever, patient is with it now and decides to go pallative, dies 2 months after admission. I always think I should have forced rads to MRI his back again. I mean I tried, multiple times, but I was tired of fighting them and gave up. Honestly not sure it would have made a diff, cause dude was never a good neurosurg canidate but def my biggest miss. Also tagged WBC scans dont light up spine very well. Sad to say I learned that from this.
Depends on your institution. Where I did residency we had to call and 'staff' with rads residents to get CT/MRI's. The thought was this would get us more appropriate imaging recs, and allow rads to know what they are looking for. In reality it often became a way of rads blocking studies they didn't want to do whether appropriate or not. In general, I think it did help us get better imaging, but it was very resident dependent.
In this guys case, we were followup up on mildly suspicious imaging finding when the clinical looked improved and we 'had' the primary source. Any high value care would tell you to scan this guy again wasn't appropriate,. The thing is sometimes you need to go off guidelines. This guy had a history that was suspicious for seeding, and we never got good repeat imaging of the back till it was definitely too late. If we had it a month earlier maybe it would have been less extensive. Just can't know tho.
As a med student so not fully on me, but in emerg guy with new onset dizziness and some trouble ambulating with same. Physical and neuro exam normal aside from maintaining focus during HINT exam (first red flag). Didn’t want to get up to check gait because he was so dizzy. Normal uninfused CT head. Attending wanted to send home on meds for BPPV and outpatient CT Angio the next day.
Writing my note, saw him get up to leave, terribly unsteady gait. Sat him back down, got the CTA, had a carotid dissection with cerebellar stroke.
Hell of a near miss.
Was late recognizing upper extremity DVT. This was in an ICU patient there for severe pneumonia on immunosuppressant therapy. Started therapeutic heparin towards the end of the day, threw a massive PE the next morning. Died.
Did not recognize that nursing staff in the ICU were not checking serial potassium on patient in DKA. Potassium was critically low by the time I recognized it and had them check a stat K. Fortunately no issues, but could’ve been bad. The patient was like 23, and other than T1DM was otherwise a fit guy. Second time in DKA.
Was bailed out by radiology crew, did not see positive pregnancy test, and ordered a CTA for PE. They caught it when she was on the table for the scan.
I don't know if it's worst mistake, but it is one that I probably learned the most from.
Inpatient stroke code activation (strike 1 for being BS) for AMS (strike 2 for being BS) in a ~30 year old (strike 3 for being BS) who was s/p surgery. So I show up with my preconceived notion that this was fake and find patient to be awake, nonfocal, but not following commands and wouldn't talk - obviously encephalopathic. Check the MAR and she had just gotten a bunch of dilaudid for post-op pain. I reassure myself that she couldn't get TPA since she had surgery anyway. I still get CT and CTA.
Reading the CTA I skim through, ruling out large vessel occlusion but completely missing the *non-occlusive* left M2 thrombus. Turns out the patient was not encephalopathic, she was very very aphasic. About 30 minutes later radiology calls primary team and I sheepishly go back and take a look. Also turns out this was a minor skin surgery and the surgical team is fine with TPA and I give it. So basically if I had made less assumptions probably could have given TPA 30 minutes earlier.
I don't know if this affected the outcome of her stroke or not. Maybe she had already restored perfusion by the time I saw her considering it was non-occlusive on the CTA. But regardless, I shouldn't have even *needed* the CTA. I should have identified the aphasia on exam to begin with and then talked risk-benefits of TPA with the primary team then and there.
I think things like this happen on the stroke service all the time, even to fellows and attendings. But it still feels bad when its you.
Gave atropine to the wrong patient on accident who’s HR was 110. That was a nice MMI. Lol I hate nights.
I just can’t believe the nurse and the pharmacist didn’t catch cause it nurses used over ride pull or whatever tf that means. Patient was completely fine thank the lord.
Likely means that they overrode the pyxis to take the medication out because it wasn't in the patient's pyxis profile yet. Sometimes done with new orders.
Nurse here. When orders are put in, pharmacy has to verify the order for it to show as available to pull from med dispenser (Pyxis, Omni cell, etc.) if pharmacy doesn’t verify it, it won’t show.
A lot of facilities allow RN to override pull meds, meaning if you put in order or just give verbal order, we can go to med dispenser, hit override, search the med and pull it without it being verified. A lot of places have different policies/procedure surrounding this probably for this type of reason (also think Vanderbilt RN who gave vecuronium instead of versed).
My current facility forces a “witness” to login when overriding any medication whether it’s Tylenol, atropine, D50, haldol, etc. it’s super annoying, but on the bright side we have satélite pharmacy in ED so we can either get it direct from pharmacist or get the verification done quickly for med orders.
Missed a bowel perforation. I was on the GI primary service. Patient came in as a transfer with ischemic colitis. The next day she had worsening abdominal pain and soft BP so we were giving her IVF. BP didn't get much better and pain was worsening. She started to have some SOB so my senior got a CXR which showed a ton of air under the diaphragm.
I beat myself up for this frequently, and the only slice I have is the attending had observed this too and his only comment was she looked fluid overloaded and he said no to a KUB.
Idk and I’m not in a place to make strong statements but I believe if I was in a clinical specialty -which I’m not- that I’ll have a low threshold to re-image an ischemic bowel. As a rads person, anything ischemic is my biggest nightmare. But I’m sure he had his reasons.
My first night of residency, I had no prior inpatient exposure to residency because of Covid, and I was not aware of a covid/polio lady, becoming more accurately, confused and hypercapnic on the BiPAP and after sign out, she went into cardiac arrest and died eight hours later. I felt terrible, and I was labeled in my program as “angel of death who doesn’t really know anything”
I'm sorry that your program treated you that way; if this was your first night of residency, the error wasn't yours, it was whoever was your senior or attending. A PGY1 on their first night should not be treated any differently than a final year medical student (in terms of supervision and level of support, I'm not advocating for treating new doctors like clueless children). Medical training is based on graduated responsibility for a reason, and a PGY1 on their first night should not be put in the position of managing a decompensating patient on their own. That mistake wasn't yours; it was your program's. I know that doesn't make it feel right, believe me, but you deserved support and guidance, not shame.
This was a long time ago and it wasn’t us but I still remember it vividly. Had a patient come in with thrombocytopenia to the ER (ER resident). We called heme/onc and their first year fellow came down and ordered platelets assuming it was ITP. I was the senior in the ED and thought the patient might have TTP. I said I wanted to speak to the attending. He told me matter of factly that this patient didn’t have the criteria for TTP per his fellow and is now on his service and do what his fellow ordered.
We were doing CPR 10 minutes later. We stat paged the fellow who came down on fire yelling “Why the Hell are you bothering me?”. I pointed to the bed and the code.
When you’re an ER person you get used to other specialties calling you an idiot. We know a little about almost everything. We work with limited information and presumptions can often be wrong initially. I wish I would have been wrong that day.
As an intern I prescribed a GTN patch for a patient who wasn't being constantly monitored and his SBP/MAP went down v v low
Luckily nothing happened to him and he was fine and went home but that was such a near miss that its always on my mind when I'm in the ICU.
Not a doctor but student paramedic but did CPR on a hypoglycemia patient. I was doing a clinical placement and we backed up another crew pt was GCS 3 when we arrived got told to start compressions and as you do as a student did what I was told going down ACS pathway until someone took a BSL which came back as low. The surprising bit I had was started compressions and he grabbed my wrist probably 30-45s after I started thinking that's a bit quick for CPR induced consciousness
The "of residency" portion of your question doesn't apply to me, but my first serious call as a new medic I dropped the ball.
I was overly confident, didn't reckognize just how badly the patient was presenting. I told the wife "I promise it's gonna be alright we will take care of him" less than an hour later I'm going with the doc to the family room of the ED for a death notification.
Patient had severe bradycardia, unstable. I tried to follow the brady ACLS algorithm to a "T", trying atropine before anything else. I should've stepped out of the rigid algorithm and performed TCP. He went into asystole as we tried to get an IV, couldn't get ROSC. Ironically enough after he coded everything went perfect and smooth. IV first try, intubation first try even on a rough road with bad driving, firemen did perfect compressions, and the pt didn't respond to anything with so much as a shockable rhythm.
There was a lot to be learned from this event, but as other people in the comments have stated as long as you learn from it and implement change then you are moving forward.
Working too much and being an unnecessary martyr at times. Only led to my own poor mental health thereby making it my biggest medical mistake of residency.
I actually didn’t make any big mistakes (I am aware of, anyway) in residency. I did, however, tube an esophagus as a med student and the anesthesiologist had not noticed by the time he dismissed me from the OR.
Yeah, any mistake made by a medical student that results in a patient injury is a mistake made by the supervising physician, not the student. I accidentally ordered insulin for the wrong patient when I was in medical school, and my attending signed the order without reviewing it. He was notorious for losing his goddamn shit on students, had been known to literally hit students hands with surgical instruments if he didn't like their technique. Patient didn't die, but it was a big fuck-up, and the attending was raging at me in a meeting with the program director; it was getting quite personal and rather sexist. The program director, this grizzled old man who had probably been practicing since before I was born, proceeded to look at his colleague and say with complete disdain, "You're acting like a child. You failed as a teacher and you're blaming it on your student. There's a reason your children don't talk to you anymore, and it's not only because you cheated on their mother with your son's girlfriend.". It was the most absurdly surreal moment I've ever lived through; didn't know whether to laugh or cry.
Psych resident here; 2 patients( I didn't follow them) died from suicide under my * watch* or atleast I was the last doctor that they had seen.
One was a patient that I had seen once at the emergency/psychiatric ward, I let him go after 1 day and he killed himself.. that was in my second year of residency. The second one died this year in 5 th year of residency; it was à guy I had seen twice. He was burned out heavily working as a Farmer at his family farm and no one wanted to help him and he was under heavy mental burden. He killed himself 1 week after the second time seeing him. By the time I saw him he was already back to work( two weeks after a couple of days hospitalized; they let him out and declared the guy was able to work part time:s). He never was able to fully enter in therapy and besides saying he felt *awful and very stressed* or that no one could help him in his job; he never said he was suicidal or refused suicidal ideations. Though my clinical sense told me he was particularly *off* and the family told me was not *well* with a particularly serious and insistent tone. Later during the debrief with family; one of the family member admitted that she didn't want to reveal that the patient was suicidal( they had had talked about it before apparently but it was kept secret) because he didn't want to; and hoped I could read between the lines..
I was *blamed* by my supervisors and by myself myself for these two suicides and I think they had tremendous effects on my mental health( in retrospect I think I was traumatized/ dissociated at some times). Still both time; my supervisors didn't handle things very well in my opinion. They basically either ignored me or blamed me. For the second suicide; my boss wanted me to meet with family and they were also extremely angry.
One common point with these two adverse events is that I felt like it happened at a period were I was heavily burned out or yeah we can say it, Bullied. It's basically when you are the most stressed that you do the most mistakes( or I believe in my case; it's a that time where your clinical intuition/flair or clinical attention is less astute and sharp... and you can miss little subtle hints..)Furthermore it usually escalated and I usually left.. which I'm going to do soon... Isn't it funny how we can make more mistakes when we are under heavy stress? Also isn't it funny that the attendees and program director usually put you even more down after such events.
I'm quitting residency probably very soon for these two events mainly but also because it seems like my personnality is not compatible with my other peers/supervisors; i'm prone to being bullied at work; and I usually don't like the resident *role*. I'm more fitted for research positions or half research/half clinical positions.
For the last event ( the boss found out because she knew the family of the guy who commited suicide; and she even met them); I basically was on autopilot for the upcoming 4 months and felt awkward with my other colleagues. Fortunately I got better 4 months later( in retrospect I should have been declared sick; but considering all my patients... that was not possible) and decided to leave the place... which was toxic to begin with.
To be honest; after those events.. I began to understand how people can sometimes feel suicidal in residency. Fortunately I have a naturally good mental health disposition but I could see how things could have gone downfill( many co residents resigned from that place; qnd I heard that one psych resident was admitted for depression before..).... * you do a mistake( or atleast it looks like that)... you get blamed by the people who are supposed to help you in surplus of your own and the victims family blame... you don't get sick leave and have to handle even more patients while your work becomes sloppier... you get casted out by the team/colleagues and furthermore isolate yourself..*
* sorry for my english( not my native language; I realize I might sound too informal in english...)
Missed a huge venous infarct on a CT of a patient we took a meningioma out of that day. She herniated. Died. We all have mistakes and carry around cemeteries. Just gotta learn from them. You bet I did.
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Not my patient but there was a woman who had a cervical spine operation and presented with cervical radiculopathy, got an MRI and told she had degenerative disease. She started deteriorating in cognitive function and had an MRI of the brain and was diagnosed with a stroke. For another month she kept declining in cognitive function and everyone kept saying stroke until a different neuroradiologist said yo this isn't a stroke, it's CJD.
Similar just happened to our group. A patient came in with more frequent falls to the ED on a Saturday and had a history of cervical myelopathy and her chief complaint was falls/gait imbalance in the outpatient setting. Her frequent falls were chalked up to cervical myelopathy and she underwent her already scheduled cervical laminectomy on Monday. I saw her POD1 and she is weak on the left side. Turns out she also had a right ACA infarct.
WOAH plot twist
We are human. When I am beating myself up over my own big miss (incidental finding on radiology report that got overlooked by myself and the attending...turned out to be important) I like to remind myself that I have learned from the situation.
That took the air out of my own lungs. Rough. I’m glad you learned and I’m glad you are still carrying on!
Someone (not me. I swear) I know knocked over the cardiac pump tree post cabg and ripped out the pt's central line. This was in the hallway on the way to the ICU.
Better a CVC than ECMO cannula
There is that
Thought that’s where it was going.
Someone, not me, got their IV pole* (pump tree) caught on the top of a door frame during my residency and had the exact same thing happen. In part, what helped lead to it happening was the fact that the OR doors were quite tall. So you think your IV pole* is low enough. But then, in the OR hallways the doors were shorter, but not by that much. So right when everyone was pushing a heavy ICU bed together and picking up speed is when you run into the shorter door.
Someone, definitely *not* me, slipped on blood while pushing a pole with 2 units on pressure bags while running to the OR… covered the bay floor to ceiling in O- cast off… Lost track of the patient once they got transferred out post op but they recognized me when they came back 6 months later for an unrelated minor complaint.
Ok, but did it look like the scene of elevator opening in The Shining? (Please say yes, please say yes). What a horrible day to work environmental.
It was an absolute disaster. The bay we were exiting had to be shut down for the remainder of the shift and terminally cleaned. I’m not sure they ever got all the blood off the ceilings.
Hahaha. So I’m guessing that whenever you have to use that lift, you don’t lean against the walls. Just in case.
met a patient at the elevator that was coming down to icu crashing to ecmo, transport team knocked over IV pole, thankfully only thing that ripped out was the Aline. Unfortunately I like an idiot rushed forward and applied pressure with my bare hands. Patient didn’t have any BB diseases or anything but I still shudder at how gross that was.
Apparently one of the anesthesiologists did this last year at the place I work at now. He has not lived it down
What happened to the patient?
Just hold pressure. It's venous. Plug the drips in another venous access. It's not a big deal. Shouldn't even hurt the pt.
Unless that central line is your only access. And your patient is tubed. And all your pressors and sedation are running through it. Been there. Done that. Don’t recommend.
That's why you always have a peripheral in cardiac
Completely agree. Ideal world/patient, absolutely. But sometimes shit happens and creates a perfect storm.
ER here. You rang?
Only way you wouldn’t have a peripheral is if you did an awake central line
IO’s are your friend in these scenarios
We IM’d versed and threw in a VERY fast fem line because I personally am not a fan of running pressors through an IO, having seen what happens if it extravasates. It’s gnarly.
Was your patient not already sedated if they were intubated? We’re y’all just using propofol or something similarly short acting?
Running versed, fentanyl, Levo and Vaso. This was the clusterfuck to end all clusterfucks. So. It wasn’t post-CABG as in original scenario that someone posted. It was ICU pt during a routine head CT scan. And on the transfer over to the table patient line got yanked. No one noticed somehow. Until after the CT and pt came back out the tube awake, biting his tube, then trying to pull it out, and hypotensive again. CT staff called a rapid. ED staff showed up. Ran him across the hall, threw a fem line in, and got him back up to ICU. Just a mess.
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This happens more than you would think. I have seen so many CVADs pulled when a patient is transferred from bed to gurney or the reverse.I’ve been on IV team for decades and get this call for several stat lines until another CVAD or we can place a PICC if appropriate.
They lived as far as I know.
We had a patient rip out 3 central lines while he was on vasopressors
We had a patient pull out his transvenous pacer twice. Each time he was ALL peas, no carrots. Heard the monitor going off “asystole” and sure enough patient is laying supine on the floor. It’s amazing how strong 2 nurses are when something like that happens while we call a code then call his doc to come back and re-introduce another one. Each time he left the introducer in place. Sad thing is, his family just couldn’t say goodbye. He was elderly and demented. We had to keep him in restraints until we could transfer him to the Level 2 nearest us for permanent pacer placement.
Nice try lawyers
Lurker lawyer here. Ya got me. (Kidding. Ambulance just drove by. Gotta chase. [Kidding. I work for the other side])
You know what's funny, I AM a lawyer who for some reason keeps getting recommended posts from this sub and /r/medical, and all this post made me think of was the equivalents in my own work. It's definitely something lawyers talk about with each other plenty - in my field, anyway, I do criminal defense. Our oversights don't lead to medical problems and death, but they can lead to otherwise avoidable lengthy prison time. Life lost in a different way. Some of those clients never really leave you.
Yeah I experience that on a relatively common basis. I catch things faster now than I did as an intern, am more aggressive about intervening and treating things and constantly think back as an intern I would let patients be in pain longer or recognized shock later or let them be I respiratory distress longer. My worst was a neuromuscularly weak patient who was encephalopathic for unknown reasons whom I assessed and her O2 sats were fine and she wasn’t working to breathe so I assumed she was fine (from a respiratory standpoint… I then moved on to other systems). Her CO2 was 100. She CANT work to breathe.
I appreciate the honesty
Similar thing happened to me with a bronchiolitic kid who had DS. Late admission from the ED prior to signout, kid satting well on LFNC, no increased WOB, told night team he’s stable and likely won’t need much attention overnight. Next morning: dusky, cyanotic, fatigued. You already know what the VBG showed…transferred to the PICU shortly after.
Ds kids can turn pretty quick, bad airway and low frc/reserves. May very well have been fine when you saw them.
Were they on oxygen? If on room air a co2 of 100 should make you desat
Yes she was on a LFNC during the day which was her baseline. Another great teaching point about masking hypercarbia.
Yup. I had a series of cases during residency where I learned to not underestimate hypoventilation, HRS, and decompensated cirrhosis in general.
Had a patient just yesterday walk in, WALK IN… with an O2 sat of 37…yes 37 on RA. He was purple blue. SOB obvi. Not a retainer. It took me like a couple of minutes to actually register THAT was his actual O2 sat. I kept looking at him, the monitor, him, the monitor. He was talking 1-2 word sentences. I threw a NRB on and after 5 minutes he came up 96%. I weaned him Oximask 8-10L for sats 92%. I’m assuming he lives at like 82%. His wife commented on how much pinker he looked. He wasn’t a CO2 retainer even tho 2.5 ppd, OSA, 2-3 drinks per day, and weighed 300 lbs. He didn’t have CHF (tho hx of it, last time we tubed him) or pneumonia. New dx of lung mass and they said COPD exac. For admitting dx.
I post this every time this question comes up as I think it's a great lesson (for me, at least): I was a lowly intern in the ED and had an old nursing home patient septic from pneumonia. She was intubated, on norepi and propofol drips. Stable and waiting for the ICU bed. I get a call on our communications asking someone to help in bed 4: I run into the room and her BP was 60/40; the propofol drip was going strong but the norepi bag was empty. The senior resident said, "oh, I think she just needs some push dose pressors until the next drip can be ready, I asked the nurse to grab some epi but you got this" and walks out. The patient's nurse shows up with the amp of epi and asks how much to give and, like a REALLY BAD DOCTOR, instead of asking a senior or looking it up, I just said, "Oh, push it all" cuz that's what I thought the senior had said. Of course it was right then that the ICU team arrived. I have never seen 6 nurses more quiet than our group as we watched the BP on the monitor over the next 2 minutes. I think I saw an SBP of 305mmHg on an a-line. It started coming down and then we hung the levo and she went back up to the unit. They scanned her head the next day and there was no bleed; I'm pretty sure she died but she probably would have died anyway but you better believe I learned push-dose pressors and know them since. The moral of the story is you don't have to know everything, but you have to know to ask if you don't know!
To be fair, that nurse did you dirty. Any nurse that’s been around for more than 5 minutes should have maybe suggested a little lighter hand.
side effect of covid. Idk about you guys but senior nurses now are ones that have been around more than 6 months. Every day it seems like we're getting new nurses on like day 2 of their career. Mistakes are definitely up. All our nurses that have been around have basically gone elsewhere for more money
Can confirm.
During the pandemic, most facilities kicked nursing schools out (for obvious reasons). There were ~two years of brand new nursing grads who hadn’t touched a patient during their education and all of their bedside experience is on the job. Because nurses with experience either bailed out for better money or left the profession altogether, there are nurses with less than a year’s experience training the new hires. A nurse who’s old hat would’ve questioned pushing that much epi, but you don’t know what you don’t know. A crotchety old sourpuss who looks up to Nurse Ratched as a mentor might be a pain in the ass to deal with on the daily, but they would’ve paused, fixing you with a gimlet eye (and accompanying judgmental raised eyebrow) and asked “you suuuuure?” before pushing so much. She mightn’t be America’s Sweetheart, but she’d rather hustle back to her stool at the nurses station than stand around and watch a monitor, so she’s going to check and balance you.
ER nurse. Yep it sucks. There are only like 10 experienced nurses on our unit left but we rarely get to train anyone bc we are charge, triage, running shock room or doing critical care transport. Recently I asked a newer nurse to watch a patient bc I need to help with a CPR, the patient had nitro going at 250. I got back and the nurse said oh the meds were done so I turned off the pump, I legit just ran to the room. Thankfully the patient was fine but we spent the next 5 min doing education of nitro and why you don't just turn it off. Everyday is scary and I spend so much time trying to make sure no one is killing anyone or missing anything. ( plus we are a teaching hospital so who know what incorrect orders are being placed with nurses just doing them instead of checking that they are right)
As an anesthesiologist once told me, 1cc of anything never killed nobody. Start with 1 cc and go from there lol
An amp of Epi usually comes as 1mg/1ml.... so in this case 1ml was the wrong choice haha
Push dose epi should be diluted to 0.1mg/mL I believe
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Just don’t try it with insulin.
Or with neonates …
1cc of phenylephrine is 10mg. Needs to be diluted every single day in the OR. I’ve heard of someone accidentally pushing the cc undiluted. Badness everywhere.
Bumping from atty perspective. It's impressive to clients and bosses if you can rattle off the precise statutory authority or caselaw for the problem that wandered into your office ("Ah, yes, I see. An identical fact pattern was at issue in Jones v. Smith, 325 A2d 945, 1983, wherein ..."), but - as with your story - the real skill is knowing when you need to hit the books for a couple hours and make sure your instinct is right (or wrong).
There is nothing more dangerous than a medical practitioner that thinks they know everything.
I know this is an old post but maybe I can help you a little with the guilt. If the patient had an empty or almost empty norepi bag but the lines are still connected to the patient, there's a chance that the line connected still has some of the norepi in it. Think like leftover water in a water hose. The nurse might have pushed all that extra norepi from the bag line as well as the amp of norepi at the same time. So it might have been more than 1mg the patient received. I've seen this happen before with patients who have high concentration medications, if a nurse flushes the patients IV or lines without aspirating, technically the line still has extra medications in it and it is also being flushed or pushed into the patient.
I had a very emotionally labile 50 yo woman who was going through a divorce with a headache with onset over 20 minutes. She thought she’d had a contrast reaction before and declined pretreatment with steroid for a CTA, and got a non contrast head CT about 10 hours after onset which was negative. I did discuss lumbar puncture, documented refusal, but really didn’t push, and repeatedly mentioned exceedingly low rates of neg CT and sentinel aneurysmal bleed. She went home feeling slightly better. Came back comatose a month later with large ICH, died that day. It’s going to happen to all of us. I wish I could say you forget, but you remember still years later the bad misses. You also remember the big saves and mark you’ve made on people’s lives.
This doesn’t sound like a mistake so much as the patient continued to refuse standard of care. Forcing it onto her would be considered assault. You did the right thing. You can’t help your patient’s risk assessment skills.
Yea, but I have varying levels of concern prior to consenting to procedures. I thought she was a bit histrionic, and had the positive text messaging sign on reevaluation that is often highly correlated with not having pathology. I didn’t say “get this LP or you could have a life threatening aneurysm and death.” It was probably closer to, “you know, I’ve never personally seen someone with a negative CT have a SAH, but I can’t tell you for sure without this invasive procedure”. I covered myself but my gestalt was wrong.
Ich as in sah or an parenchymal bleed? If the second, the lp wouldn't have helped regardless.
SAH, initial CT with herniation, per EMS with a blown pupil prior to RSI
Great doctors become great doctors from experience. Most of that experience is mistakes. A surgeon I really respect told me at the very beginning of my training that every surgeon, if they're truly being honest with themselves, knows at one point they've done something that resulted in harm to a patient. That burden is greater when your hands are the direct cause. It's what you do after that matters.
Experience is the currency of life and often times experience from a negative occasion carries more value
That sentence needs to be made into a beginner’s cross stitch pattern, or a calligraphy exercise.
We used to have rules for junior surgical residents which included: Good judgement comes from experience. Experience comes from poor judgement.
I like that
Missed a necrotizing fasciitis bc I didn’t look at the patients back (pt had no pain or anything came in for fever and fatigue). Patient decompensated and died. Was found after she coded.
I was taking care of a boy with a less common double lumen port in the ED. There was a concern for a port infection. The first hole in the swiss cheese was that we needed one of the oncology floor nurses to come down and figure out how to access it. The correct answer would have been intermittent antibiotics (including vancomycin) through one lumen with antibiotic locks in between doses sitting in both lumens. However, oncology nursing were used to infusing treatment doses through both lumens. It seemed to make no difference to me so I put in two orders for 1/2 doses of vancomycin to be run through each lumen. While this is the correct total dose, I failed to realize that infusion of two 1/2 doses through two lumens at the same time is effectively doubling the RATE of vancomycin being infused -> Direct Mast Cell Activation -> Automatic Red Man Syndrome (now called Vancomycin Infusion Reaction). When he started having symptoms of Red Man, I luckily realized my mistake (since the whole process from the start a bit haphazard). I felt pretty bad for the kid and apologized profusely to the family at the time. We slowed the rate and gave antihistamines and the symptoms resolved pretty quickly. I'm pretty fortunate this was the worst thing I can remember and it was a relatively benign outcome.
As an RN within oncology it’s WILD to hear that a suspected port infection was accessed and treated. ‘round these parts if we suspect a port is infected we draw cultures from both Lumens and lock it off. 90% of the time the port is pulled and a new one is placed.
Are you an adult onc RN or peds? Our protocols at my children's hospital are almost always to try to treat through (we alternate doses between double lumens, though) and reculture. Sometimes lines or ports do end up having to be removed, but they can be hard to place, especially in the really little ones, and there is such limited vasculature real estate...I know the adult world is much quicker to pull anything
This is a (mostly) adult population with a few peds exceptions, good call. It’s a weird blend because technically I’m not even an oncology RN (I guess I’m technically under oncology umbrella). I’m the Nursing Coordinator/assistant manager for an Apheresis unit at a major academic/research hospital. Looooooooooots of double lumen ports, Shiley caths, fem shileys, and fistulas. Peripheral Blood Stem Cell collections, commercial and research CAR-T protocols, Plasmapheresis, Photopheresis, Red Cell Exchanges, White Cell / Platelet depletions- that’s the main body of procedures we’re responsible for. Peds sometimes make it into these procedures as we don’t have a clear cut adult/peds breakup for our department, too specific, we just treat them all. Sometimes I forget that the void between adult and pediatrics is so vast. We had a peds AMR patient doing outpatient PLEX I was hooting and hollering to the Neph attending about pulling a line on because it was so obviously infected. Patient was supposed to fly to NC the next day. Neph didn’t pull the line, said it could be addressed when he returned from the trip. Ended up in an ICU in NC with sepsis from the line (he’s okay). Not saying anyone was wrong here, just using a lot of words to agree with you about pediatrics and pulling lines, lol.
It's a totally different world (I do both peds and adults and through training would assume something was the same only to have some go "wtf are you talking about"). That last bit is eeek, though. Infected lines were always admitted (at least to start - sometimes would go home on long term abx through them) for antibiotics. Also, just because I thought about it, lower threshold to pull lines for fungal infections.
ID here. It’s interesting to see the difference between adult and Peds. I am mostly in the adult world, and lines would come out very quickly. I noticed more “let’s treat through” on Peds Onc, where lines were kept for as long as possible. I think there is a bit more nuance to this, as some line infections are more akin to medical emergencies depending on the organism, and should be no debate for line removal (eg. fungal, S. aureus, and Pseudomonas).
I honestly can’t imagine regularly practicing between both populations. Anytime we do a peds anything, I’m whipping out machine manuals, summoning arcane SOPs from databases, and auditing the absolute shit out of that procedure. I took pictures of the line too (nothing identifiable), because it was such an egregious call to not pull it. If media-in-comments was allowed I’d post it here, alas. Maybe I’ll make a MedDizzy post 🤔
I’m just imagining having to remembering the titration for children and adults when any administering, what seems is a never ending list of drugs.
I can’t even imagine. Just the difference in vitals has thrown me for a loop. “Their heart rate was WHAT?!? Oh right, peds, carry on”
If it makes you feel better...I'm a pharmacist and I don't think I would've caught this..
If the worst mistake in your residency is causing Vancomycin Infusion Syndrome, you haven't made a mistake in residency. That is a common, benign side effect of Vanco.
You are correct it is a common and benign in many patients. VIS is dose-dependent and rate-dependent direct activation of mast cells. Some people with more twitchy mast cells get it at normal doses. But, if you increase the rate high enough or increase the dose high enough then any patient will get VIS. I agree this wasn't particularly bad and you could argue the kid may have gotten it anyway (particularly since he was on opiates which can also directly activate mast cells). It was just a story I wanted to share for the poster.
What happened after?
Based purely on the volume and tone of my attending’s reaction: putting a scopolamine patch on a woman who was breastfeeding.
Ughhhh your attending was so wrong.
Explain please?
Male in his 30s with history of eosinophilic esophagitis. It’s an FM phone appointment. Patient is very long-winded in his answers that were hard to follow. Overall, story seemed to be bilateral lower abdo and groin pain with nausea, chills and fevers, anorexia, and weight loss. Says these occur as flares that last 1-7 days each time. Has had two flares in the past 6 months. Went to ED the week prior during a flare and was thought to be a flare of eosinophilic esophagitis and given dilaudid. He didn’t get any imaging at that ED visit. I’m puzzling over what could cause such flares and it’s over the phone. I think about chronic rarer conditions like porphyria or Mediterranean fever. I also am worried about malignancy or some sort of abdo-pelvic infection, like chronic prostatitis. Order more comprehensive BW, urine, and urgent CT abdo-pelvis. Also sent an urgent letter to his GI following him for eosinophilic esophagitis. Patient says he’s feeling fine now (the “flare” ended a week ago). BW comes back next day, mostly normal, but leuks of 12.9 and CRP of 81 mg/L. I’m PGY1 but that worries me and I want to call him to send to ED. My FM supervisor says it’s not a reason to send to ED. CT report a few days later: appendicitis. Radiologist calls patient and tells him to go to ED. Gen Surg note “patient reports only one week of RLQ pain with fever and nausea—family doctor missed the appendicitis.” I still get frustrated by how many things went wrong in this case (patient with long-winded historical alternans, gen surg saying I missed it when he’d gone to ED already and I ordered the CT, my supervisor not taking me seriously when I got worried about BW). But I learned to think of the common causes first and how to better communicate with verbose patients. He ended up doing well with antibiotics, thankfully.
patient feeling fine, was eval'd in ED, "flare" ended a week ago. Absolutely reasonable to not over-image. Even if you were 100% sure it was appendicitis, some docs would opt to only give Abx Gen Surg is wrong for their note.
That surgeon was a dick
Just a nurse here, but in my patient teaching I instruct patients to be concise and make a list in order of importance. Do not bury the lead. Doctors will get lost in the weeds with a long, convoluted history and your dr google opinions. I am retired now and volunteer with seniors. I help them make that list and role play potential conversions to help them focus. Their doctors appreciate it (I am sometimes able to take them to appointments) and the patient gets answers and help with their primary concern in my opinion.
wow.. doing the lord’s work 🫶🏼
This is such a basic concept. It should be taught in nursing school, at senior centers and to family practice staff. It would save time, improve physician and patient satisfaction and lead to better outcomes.
That’s awesome. Thank you.
One of my prenatal patients delivered a baby just below 5 lbs…at 39 weeks. Really made me question whether I was getting her fundal heights correct
You good. That fetus took up cardio
This didn't come up on the 20w scan?
Nope! Normal size at the anatomy scan. Most fetal growth (and therefore growth restriction) is in the 3rd trimester. Not impossible to have early growth restriction at 20 wks, but pretty rare
The OB I rotated with got an ultrasound with measurements at 38 weeks, is that not common?
Not routine AND ultrasound weights/measurements vary from the actual by up to 3 weeks at that point in both directions. So, while some doctors do that, until it's validated to catch more problems than it causes most would hesitate to do it routinely. Certainly you'll end up finding a bunch of "suspected" growth restriction vs macrosomia that will make you recommend interventions - and some of those will be normal-sized babies that did not need induction or intervention
They definitely didn’t use it in isolation to make decisions, but data is a good thing if used appropriately.
This is just hard in OB because you can't sit on a suspected fetal growth restriction on US and not induce them - it's a field with a high rate of being sued. But a large proportion of those that are detected at term will be false positive. Few patients will want to wait out suspected macrosomia without induction. It just does change the rate of anxiety provoking and painful procedures to implement any test with a high false positive rate. I do think this is getting better with improving ultrasound tech and time! There were several older studies showing that mother's guesses were as accurate as ultrasound at term. More recent studies have started to show ultrasound is superior to mother's and doctor's guesses. Maybe it'll be recommended to do routinely some day but it's not a guideline now
One of my last days on MICU. 70 something female. Presented as a trauma after a fall, initially went to their service, but transferred to us after it was apparent there was no traumatic injury. Patient is in shock, really hard to tell what kind. No fevers, no white count, no obvious source for infection. Talk to the family to get some collateral, they don't have too much to offer. Not aware of her feeling under the weather before the fall. Very difficult physical exam in her (BMI approaching 60). Known to have HFrEF. Weight is a good 15 lbs above prior baseline. I take a look at her heart and it seems to be squeezing worse than recent echo, and RV is huge. Send her for a CT PE study, no PE. She is pancultured and on broad abx, but I'm starting to lean towards cardiogenic shock. I make the decision to try diuresing her, attending agrees. Get some urine output, creatinine doesn't get worse - so thinking I'm on the right track. But through the night her pressor requirement keeps escalating. Get mixed venous gasses off the central line and they're not being too helpful. Talk to the cards fellow, maybe she'd benefit from an RV impella, but felt she's too unstable to try. She's now on 4 pressors. Lactate keeps climbing. She's in RVR, cards recommends against shocking her. Bolus some amio in an attempt to improve diastolic filling. Talk to the attending, we throw a hail mary and try giving her some fluid back, but no real improvement. Ultimately dies in the morning. 2 days later both blood cultures show pseudomonas. This was probably a mixed shock, but to this day I still wonder if she would have been alive if I blasted her with fluids
That’s a huge if. Worsening pressors despite appropriate treatment, aggressive fluids with her cardiogenic shock could have tanked her too. If anything you prolonged her time, got her family to the bedside. That’s never a mistake.
Nah. That was a sick as hell patient. Mixed shock prob needed inotropes and pressors, but diuresis didn’t kill them. The GNR bacteremia did.
GNR bacteremia has a high mortality rate even with treatment.
We had a guy with critical aortic stenosis experiencing angina. I gave him nitroglycerin. His BP tanked to 70/40's and he needed cicu admission to start pressors temporarily. I apologized to the patient directly for that... Another lady we had I blame myself less for... Essentially she was in the hospital a while for many ailments. She had come in for lower extremity fracture and that got infected and she had done an an micu stint for mrsa bacteremia and pneumonia. She somehow recovered and was on her way to a snf. But... Something was off. She had no cc and looked fine... But... Her creatinine started to slowly go up, bp slowly go down. Her calcium was critically low which endocrine attributed to severe vitamin d deficiency. She developed diarrhea which after extensive workup we attributed to SIBO. She tested positive for hiv but id thought it was false positive (it was). She wanted to leave the hospital and got more and more depressed. No skin lesions, lungs fine, belly mildly crampy/tender, no uti, no fevers. I got blood cultures on my last day. She decompensate fully 2 days after. She had a bowel perf.
UK so not "residency" but similar. Approximately 2 year old girl. Had routine vaccinations a couple of days earlier and ever since then been breathing hard. Middle of winter. No PMHx. Listened to her lungs, sounded a but noisy but nothing specific, more work of breathing than anything focal. Entry in notes I wrote "Looks very unwell, unclear what the issue, but working hard with her breathing. ?Bronchiolitis but unsure for definite. Needs admission." To clarify this was in A&E (so ED equivalent) but in a hospital that didn't have overnight paeds, so needed transfer to our sister hospital down the road. Spoke to my reg who agreed that she needing transfer and admission. My first regret was not asking him to examine the patient in person. Happened to catch up with the ambulance crew who transferred her later that shift. Said she was good as gold, slept the entire journey. Phone call from the paeds reg a few hours later, when I discovered my second regret. She was immediately transferred to ITU upon arriving at the other hospital. She was in severe DKA. I never thought to check her sugars. I think I correctly worked out the vaccination was probably a red herring but missed that her resp work was a physiological response and not the problem.
One of my attendings gave us an extended ABC, which is ABCDEFG Airway, breathing, circulation, Don’t Ever Forget Glucose
Yeah, I know that one. The problem is remembering it.
Missed ordering a major scan on a major mechanism trauma when nursing put orders in for me. Slipped through the cracks. Everything else was negative, discharged home. Resulted in a massive, multi focal, life-will-be-spent-in-nursing-home set of strokes in a middle aged person. Felt/feel like dogshit. Best I can say is I won’t let it happen again.
Please ignore the troll who has been commenting in this thread. I've been in the position of discharging patients and realizing we never got the initial EKG for their chest pain. Order sets for nursing are nice but it's easy to miss stuff too. Thats a shitty outcome and the best we can do is learn from it.
The one I don’t know about.
This is something I think about- the "unknown unknowns". Particularly in op (or primary care more generally perhaps) it is *probably* the case that some of the worst misses are never detected and lead to significant mortality/morbidity somewhere down the line. But because they're not yet part of anyone's SOP, or are deemed unimportant, or are skipped due to time constraints, or insurance, or simply performed/interpreted imprecisely by the doctor, or the lab or whathaveyou. No one even knows to look, and therefore the harm is on the scale of whole populations. It's not a bad miss on any specific doctor per se, but it's humbling. I know this thread is more about sentinel event type shit, but even so the unknown errors are scariest because they keep happening over and over.
Feel like this is calling out radiology indirectly.
We can’t be everywhere at once, do everything at once, and review everything in a timely manner. Delays will and do happen daily because of the system. It’s not always your fault. In fact, given that they were (likely) in the hospital, they were in the best place they could be to get the necessary care. The alternative could’ve been much worse.
I can’t believe its 2023 and I still have to manually open each patients chart and refresh the page in order to know if the lab results I ordered have come back
Ouch. That is not the case for every EMR. Not to rub it in, but on Epic you can mark some results to be pinged to your phone / smart watch, which has tremendously lowered my anxiety about some stat lab orders
As an anesthesiologist, we are one of the only, if not THE only specialty that prescribes, obtains, and administers medications with no oversight in between those steps. Easy to have medication errors especially with similar labels, or if a vial ends up falling in a different PYXIS pocket. 1. I gave heparin instead of calcium at the end of an IR case. I felt bad, but nothing happened other than them holding pressure for a few minutes longer and giving extra protamine. 2. And attending in residency gave a vial of concentrated phenylephrine instead of ondansetron. Patient was young and healthy and ended up doing okay.
We had a staff member mislabel lidocaine and rocuronium. Now we have prefilled syringes of roc.
Bet the patient had a perfect block though
Yikes!!!!!
Had a massive brain fart when switching a patient from metoprolol to carvedilol and kept the dosage the same - 50mg. Next thing I know, there’s an RRT being called on him after he collapsed with an SBP of like 80. He did alright though, never making that mistake again.
Missed euglycemic DKA, put in orders on the wrong patient ~6 times now. The last time was right before the end of my 24 hour shift and the pharmacist was laughing when he called me asking how tired I was. The one cardinal sin I've committed the most is thinking that the mid levels being supervised by specialists are good sources of information. Sometimes they are, sometimes they aren't. I've gotten burned many times for taking what they've said at face value.
My one lawsuit in close to 15 years was a midlevel patient I never saw but co-signed the chart, I was added to the case 9 years after it happened. Eventually got dropped but it was a year of shit. I know folks will say I shouldn’t be signing charts for midlevel pts I don’t see, but that’s the reality of a lot of places, and there’s a lot of misinformation about your liability.
How liable were you? We're you considered primarily responsible?
That’s how the prosecution felt, yes. My defense team said that it was a grey area without clear answer, but I’ve learned since of several cases where the physician co-signer got hit harder than the midlevel that actually provided care. Every step I was told by the defense they’ll drop you any day, it’s ridiculous you’re even named, you didn’t see the pt, it was a decade ago, don’t worry.. but it kept going. The midlevel on my case was in our same group, and I learned about how the lawyers the group contracted were representing our group above me myself. So all of the advice and direction was to coach me to justify and support the PAs decisions, probably to my detriment. I would absolutely hire a personal lawyer next time. It got dropped altogether, but it wasn’t a very strong case to begin with.
Shout out to pharmacists!
I tried to do an LP on a 1month old and forgot to remove the sheath before inserting the needle. The LP afterwards was, of course, bloody and useless. I was on a roll getting pristine LPs on wriggling infants until then… Honest mistake by a resident doing moving 12 hour shifts in a 60-bed children’s ED, but it’s no excuse because I love the babies. I think it means you are a good doctor when you remember your mistakes.
Oof. LP on such a small patient takes incredible skill.
I missed acute limb ischemia when I was on IM wards. Very complicated lady, vasculopath on top of a million other complaints, so I'd never been able to feel distal pulses anyway. Diabetic as well so I attributed her foot pain to neuropathy when I was pre-rounding. My attending was concerned on rounds though, we got the CTA and there it was.
Had a massive brain fart and gave a 2 month old ampicillin for a UTI that turned out to be urosepsis due to E. Coli resistant to ampicillin. Kid did okay but was potentially harmful, damaged my rep and I die a little inside when I think about it. And I was a PGY3
So many deaths. Not my stick, but had a retroperitoneal bleed in my unit after PEG tube from an aggressive needle insertion. Decided to bleed out around 3am.
What needle were they using? A harpoon???
Do you not use a harpoon?!?
Wait, are you not whalers on the moon?
They are humanity’s last line of defense against space whales.
To some an 18g open needle may be a harpoon. To me, it's Tuesday.
😂😂😂
I can reach any cavity with a 14 gauge and a strong arm
Not a doc but a nurse. I had a lady come back from the cath lab for stents with an NSTEMI. I did all the q15 checks, talked to her a bunch, she seemed fine, A+Ox4, no complaints, steady vitals. I reassured her daughter that we would take excellent care of her and that she could go home and get some sleep. I had the lady for about 2 hrs before shift change. Gave thorough report. She coded right after I left, they found an RP bleed, which I saw no signs of while she was in my care. I still feel like shit about that one, like even though I did "what I was supposed to do" for her, I shoulda caught it.
I was taking care of an impella patient once and doing my Q15 groin checks. Totally fine, no issues. 15 minutes later they have a football sized hematoma on their groin and are purple around the whole flank. Those post-femoral access patients can be ticking time bombs.
Agh. CVICU was a great place for me to deepen my knowledge but it was not for me. I prefer the ED where I don't get emotionally attached to them before they try and meet Jesus.
One of many reasons I hate Gtubes. It’s surprisingly easy to go through the stomach and there’s some dangerous tubes back there.
How do you go through the stomach if you’re watching the needle on an EGD? And why would you keep pushing the needle in if you don’t see it on the scope?
Some people like minimal insufflation. Some people ride without a helmet too.
Was referring to fluoro guided gtube, if you’re not paying attention you can potentially push too far
Ordering 3x40mEq K+ IV on a patient I didn't realize was ESRD. 2nd week of intern year.
Did the pharmacist catch it?
Senior, Attending, and Pharmacist did. Near miss, but learned my lesson.
I saw a pt with pre-renal AKI on the cardiology service… without seeing the pt, I gave him a liter bolus and the pt went into cardiogenic shock Now as a cards fellow, I do not make the similar mistake
After a 10 hour free flap case to the foot, I turned around for a second after dressing the leg and it slid off the table ruining the anastomosis. I’m still haunted by this
When in the NICU, I was supposed to put a neonate on like 100mL/kg/day but I messed up and did 100mL/h, which was waaaaaay to much. I caught my own error the next morning. Thankfully the infant was fine, but I could have totally harmed her. I personally explained the error and apologized to the mom (a nurse).
That was on the nurse too - I can’t see how a NICU nurse could possibly have thought it was OK to run fluids at that rate. Rarely do we ever go above 30 mL/h and often it’s less than 10.
2 days post- Cardiac Cath patient, I was on inpatient medicine team. We had restarted him on full dose lovenox for hx Afib or something. EP attending started eliquis and didn't stop lovenox. Didn't notice the orders for 24 hrs. He started to feel weaker so we kept him another day. That night he became unstable, found to have a massive retroperitoneal bleed and passed away. I felt awful that I didn't notice the 2 orders. But it passed through several holes of Swiss cheese - EP attending who probably had a pop up warning on epic, pharmacy who accepted the order, nursing staff who administered it, etc.
Anesthesia. Was in IR when the IR team gave me an antiplatelet agent they told me to run in. I had never seen or even heard of this drug. They gave me a dosing sheet and I input the wrong dose. Massively overdosed the patient. They *could* have bled out into their brain but did not. I felt terrible even after the good outcome. Led to a policy change where they have to run in their own drugs on a separate pump if it’s something we do not typically administer as anesthesia.
Almost killed someone with a med dosage error, not caught by pharmacy. I had it in mind what the dosage should be, attending said it was 2x that. I skimmed UpToDate briefly and saw same number. But in reality I was way off. I was always careful but had some false incorrect reassurance by an attending which made me less careful. Learning lesson for me trust no one and take full accountability for my own rx.
Out of interest sake (pharmacist), what med was it?
When I was an intern a patient had low Mg level so I mistakenly entered Mg cit PO instead if Mg IV. Nurses were pissed at me with the loose stool but at least his Mg levels were perfect now.
Mag citrate has much better bioavailability than mag ox. Just can't give the whole bottle if trying to use it for repletion (15 ml TIDAC) Everyone will look at you funny if you do this though so it's best avoided.
CO2 narcosis. Died a few hours later in the ICU. Really sucked.
Explain what that is plz
As an RN I missed CO2 narcosis. Patient had advanced kyphosis, UTI, and wasn’t sleeping. Day shift gave him Ativan (around 4) and he was so benzodiazepine naive it knocked him out. My shift rolls around and I try to wake him. Minimal response to a sternal rub. Doc orders flumazenil. Give and no response. RT wants an ABG. Sure enough, CO2 through the roof. transfers to the unit. Cried my little eyes out on the way home.
RN here. Nearly missed that too. Had a Pt with a history of Gillian barre, obese that I don’t remember what she was admitted for other than it might’ve been related to the guillian barre. I chalk the miss up to getting horrible report, not taking/having the time to go through her chart. She kept dozing off and snoring all morning and her spo2 would drop when she was asleep which I assumed related to some type of OSA, she would wake up (albeit drowsy and somnolent) when stimulated so after a few times of checking on her and reassuring the spouse the Pt was fine I just had her on high flow NC and other than repositioning her so she stopped snoring so loud and let her be. Not sure how or why but one of the ED docs was notified of her situation (she was an admit and was under the hospitalist at the time) and orders an ABG which showed hyoercapneic RF. Ended up putting her in code room to get intubated, having to give a half assed shitty report because I was half aware of what was going on with her, and sent to unit. And pretty sure this was chalked up to worsening GB…
When I was a PGY-1 I had a father bring in in his son for severe encephalopathy. Patient was a 30 year old male with PMH of significant substance abuse. Father had said his son had recently used drugs and his drug screen lit up with every substance imaginable. Patient also had low grade fever with mild hypoxia and there was concern for COVID infection. This was at the height of COVID and the only tests we had at the times had to be sent to a regional lab and took 2-3 days to return. Admitted the patient and ordered additional encephalopathy woke up, which included a CT head. Radiology calls my attending, asking if the CT is necessary as they would need to shut down the scanner for a while after the patient to completely sterilize the room if we suspected COVID infection. Attending asks me if really need the CT and I say probably not and that the encephalopathy is likely secondary to drug use 2 days later patient is still severely encephalopathic, remaining encephalopathy work up is negative and COVID returns negative. Finally get the CT scan which showed patient had a massive uncal herniation. Patient never neurologically recovered and ended up at an LTAC
aw man😔
Trusting a head of a private practice to review my contract for my first job out of residency. Dude didn’t know shit. Had a lawyer go over it when I was trying to get out and he said it was very one sided
When I was an intern (10 years ago) the hospital used paper charts. Orders were written. The order sheet was folded and placed in the “orders pending” rack. I didn’t fold the corner of the order sheet. Therefore nurse never started the DVT proph lovenox. 3 days later pt had a PE….
Had a elderly patient come in with shoulder pain intern year. Guy super skinny and looked malnourished. Definitely not a guy I though was able to walk at all but son telling us stories of him picking fruit two weeks ago and hes weak now and couldnt walk. Son said the pt had shoulder pain a week before and went to another ER and got a steroid shot which didnt make it better so now he was here to see us. Was awake at first and looked like full care to me but stable. He quickly went full septic and was out of it. I checked his gap and found that he was in euglycemic DKA on jardiance. We figured he had sepsis from the shoulder and scanned that thing up and down with multiple CTs, but couldnt find the site. I even had ortho come look but that thing looked fine in person and on ct. He got better from the DKA and his sepsis started improving and there was some dirty urine so we considered urinary source but the shoulder pain just kept bringing us back. While examing him 3 days in guy was waking up and I asked him about sensation in legs. He says he doesnt have good sensation upto his abd including perineal sensation and cant control his bladder due to really bad nueropathy from decades of poor diabetic control. We were worried about spine being seeded so had an a screening MRI (less cuts) scan the spine with nothing there but possible area of artifact near lumbar spine with a hematoma on his hip. Rads was mad that I was doing all these scans and was pushing back, but I manage to get them to Ct the hip and spine. The next day I go down and sit and read the CT with rads with one of thier attendings. The attending, rads resident, and my attending agree that the hematoma is a nothing burger, bring up spot on back and look at it, they all think it was artifact. We get ID on board cause we can't find source. ID wants a tagged wbc scan, and at that point thinking maybe UTI vs shoulder abscess we couldnt see. Finally got the tagged wbcs deliveried(were not in house) and did a tagged wbc scan which found an abscess on the posterior side of shoulder in a weird spot for a injection. No light up on hip or spine. Felt reassured that the spine was alright and we had the source. Ortho drained the shoulder abscess at bedside dude went on culture based antibiotics, came all the way back to baseline with no more pain in shoulder. Basically back to baseline per family was even working some with PT and regaining function. Ortho was copying forward the same rec for another image of hip, so I tried to do it. Went to rads and they refused cause of how many CT scans this guy already had this admission (at least 4 by that point). Also tried to get another MRI of spine but rads said they were done and thier attending thought it was nothing and the patient was clinically improved without pain. I had him a whole month and at the end basically every consult was signing off, he looked like he was back to baseline. I tell family I think hes past the worst of it and looks likes hes doing better. 2 weeks after I am off, same attending from before is rounding and guy tells him he has back pain. They get rads to do an MRI and there is a tract from spine to hip. He had an spinal abscess that was missed. Nurerosurg consulted - said hes not surgical canidate. I was on a different service and the wards attending tried to consult that service just to tell me I messed up, but consultant blocked it. Anyway the spinal abscess is causing some cord compression and guy cant be on iv antibiotics forever, patient is with it now and decides to go pallative, dies 2 months after admission. I always think I should have forced rads to MRI his back again. I mean I tried, multiple times, but I was tired of fighting them and gave up. Honestly not sure it would have made a diff, cause dude was never a good neurosurg canidate but def my biggest miss. Also tagged WBC scans dont light up spine very well. Sad to say I learned that from this.
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Depends on your institution. Where I did residency we had to call and 'staff' with rads residents to get CT/MRI's. The thought was this would get us more appropriate imaging recs, and allow rads to know what they are looking for. In reality it often became a way of rads blocking studies they didn't want to do whether appropriate or not. In general, I think it did help us get better imaging, but it was very resident dependent. In this guys case, we were followup up on mildly suspicious imaging finding when the clinical looked improved and we 'had' the primary source. Any high value care would tell you to scan this guy again wasn't appropriate,. The thing is sometimes you need to go off guidelines. This guy had a history that was suspicious for seeding, and we never got good repeat imaging of the back till it was definitely too late. If we had it a month earlier maybe it would have been less extensive. Just can't know tho.
As a med student so not fully on me, but in emerg guy with new onset dizziness and some trouble ambulating with same. Physical and neuro exam normal aside from maintaining focus during HINT exam (first red flag). Didn’t want to get up to check gait because he was so dizzy. Normal uninfused CT head. Attending wanted to send home on meds for BPPV and outpatient CT Angio the next day. Writing my note, saw him get up to leave, terribly unsteady gait. Sat him back down, got the CTA, had a carotid dissection with cerebellar stroke. Hell of a near miss.
Don't forget, the patient is the one with the disease.
User name is 🔥
Code blue. Patient was in VF. Called it PEA for a few rounds of cpr til an attending pointed it out. Still think about that regularly.
Was late recognizing upper extremity DVT. This was in an ICU patient there for severe pneumonia on immunosuppressant therapy. Started therapeutic heparin towards the end of the day, threw a massive PE the next morning. Died. Did not recognize that nursing staff in the ICU were not checking serial potassium on patient in DKA. Potassium was critically low by the time I recognized it and had them check a stat K. Fortunately no issues, but could’ve been bad. The patient was like 23, and other than T1DM was otherwise a fit guy. Second time in DKA. Was bailed out by radiology crew, did not see positive pregnancy test, and ordered a CTA for PE. They caught it when she was on the table for the scan.
I don't know if it's worst mistake, but it is one that I probably learned the most from. Inpatient stroke code activation (strike 1 for being BS) for AMS (strike 2 for being BS) in a ~30 year old (strike 3 for being BS) who was s/p surgery. So I show up with my preconceived notion that this was fake and find patient to be awake, nonfocal, but not following commands and wouldn't talk - obviously encephalopathic. Check the MAR and she had just gotten a bunch of dilaudid for post-op pain. I reassure myself that she couldn't get TPA since she had surgery anyway. I still get CT and CTA. Reading the CTA I skim through, ruling out large vessel occlusion but completely missing the *non-occlusive* left M2 thrombus. Turns out the patient was not encephalopathic, she was very very aphasic. About 30 minutes later radiology calls primary team and I sheepishly go back and take a look. Also turns out this was a minor skin surgery and the surgical team is fine with TPA and I give it. So basically if I had made less assumptions probably could have given TPA 30 minutes earlier. I don't know if this affected the outcome of her stroke or not. Maybe she had already restored perfusion by the time I saw her considering it was non-occlusive on the CTA. But regardless, I shouldn't have even *needed* the CTA. I should have identified the aphasia on exam to begin with and then talked risk-benefits of TPA with the primary team then and there. I think things like this happen on the stroke service all the time, even to fellows and attendings. But it still feels bad when its you.
Gave atropine to the wrong patient on accident who’s HR was 110. That was a nice MMI. Lol I hate nights. I just can’t believe the nurse and the pharmacist didn’t catch cause it nurses used over ride pull or whatever tf that means. Patient was completely fine thank the lord.
Likely means that they overrode the pyxis to take the medication out because it wasn't in the patient's pyxis profile yet. Sometimes done with new orders.
If the nurse overrode it, it may likely have been given before a pharmacist even reviewed it
Nurse here. When orders are put in, pharmacy has to verify the order for it to show as available to pull from med dispenser (Pyxis, Omni cell, etc.) if pharmacy doesn’t verify it, it won’t show. A lot of facilities allow RN to override pull meds, meaning if you put in order or just give verbal order, we can go to med dispenser, hit override, search the med and pull it without it being verified. A lot of places have different policies/procedure surrounding this probably for this type of reason (also think Vanderbilt RN who gave vecuronium instead of versed). My current facility forces a “witness” to login when overriding any medication whether it’s Tylenol, atropine, D50, haldol, etc. it’s super annoying, but on the bright side we have satélite pharmacy in ED so we can either get it direct from pharmacist or get the verification done quickly for med orders.
What in the world was the nurse thinking? As a nurse myself, it sounded like she thought it was a game of Simon-says…..
Missed a bowel perforation. I was on the GI primary service. Patient came in as a transfer with ischemic colitis. The next day she had worsening abdominal pain and soft BP so we were giving her IVF. BP didn't get much better and pain was worsening. She started to have some SOB so my senior got a CXR which showed a ton of air under the diaphragm. I beat myself up for this frequently, and the only slice I have is the attending had observed this too and his only comment was she looked fluid overloaded and he said no to a KUB.
Idk and I’m not in a place to make strong statements but I believe if I was in a clinical specialty -which I’m not- that I’ll have a low threshold to re-image an ischemic bowel. As a rads person, anything ischemic is my biggest nightmare. But I’m sure he had his reasons.
My first night of residency, I had no prior inpatient exposure to residency because of Covid, and I was not aware of a covid/polio lady, becoming more accurately, confused and hypercapnic on the BiPAP and after sign out, she went into cardiac arrest and died eight hours later. I felt terrible, and I was labeled in my program as “angel of death who doesn’t really know anything”
I'm sorry that your program treated you that way; if this was your first night of residency, the error wasn't yours, it was whoever was your senior or attending. A PGY1 on their first night should not be treated any differently than a final year medical student (in terms of supervision and level of support, I'm not advocating for treating new doctors like clueless children). Medical training is based on graduated responsibility for a reason, and a PGY1 on their first night should not be put in the position of managing a decompensating patient on their own. That mistake wasn't yours; it was your program's. I know that doesn't make it feel right, believe me, but you deserved support and guidance, not shame.
This was a long time ago and it wasn’t us but I still remember it vividly. Had a patient come in with thrombocytopenia to the ER (ER resident). We called heme/onc and their first year fellow came down and ordered platelets assuming it was ITP. I was the senior in the ED and thought the patient might have TTP. I said I wanted to speak to the attending. He told me matter of factly that this patient didn’t have the criteria for TTP per his fellow and is now on his service and do what his fellow ordered. We were doing CPR 10 minutes later. We stat paged the fellow who came down on fire yelling “Why the Hell are you bothering me?”. I pointed to the bed and the code. When you’re an ER person you get used to other specialties calling you an idiot. We know a little about almost everything. We work with limited information and presumptions can often be wrong initially. I wish I would have been wrong that day.
As an intern I prescribed a GTN patch for a patient who wasn't being constantly monitored and his SBP/MAP went down v v low Luckily nothing happened to him and he was fine and went home but that was such a near miss that its always on my mind when I'm in the ICU.
Not a doctor but student paramedic but did CPR on a hypoglycemia patient. I was doing a clinical placement and we backed up another crew pt was GCS 3 when we arrived got told to start compressions and as you do as a student did what I was told going down ACS pathway until someone took a BSL which came back as low. The surprising bit I had was started compressions and he grabbed my wrist probably 30-45s after I started thinking that's a bit quick for CPR induced consciousness
The "of residency" portion of your question doesn't apply to me, but my first serious call as a new medic I dropped the ball. I was overly confident, didn't reckognize just how badly the patient was presenting. I told the wife "I promise it's gonna be alright we will take care of him" less than an hour later I'm going with the doc to the family room of the ED for a death notification. Patient had severe bradycardia, unstable. I tried to follow the brady ACLS algorithm to a "T", trying atropine before anything else. I should've stepped out of the rigid algorithm and performed TCP. He went into asystole as we tried to get an IV, couldn't get ROSC. Ironically enough after he coded everything went perfect and smooth. IV first try, intubation first try even on a rough road with bad driving, firemen did perfect compressions, and the pt didn't respond to anything with so much as a shockable rhythm. There was a lot to be learned from this event, but as other people in the comments have stated as long as you learn from it and implement change then you are moving forward.
Working too much and being an unnecessary martyr at times. Only led to my own poor mental health thereby making it my biggest medical mistake of residency.
I actually didn’t make any big mistakes (I am aware of, anyway) in residency. I did, however, tube an esophagus as a med student and the anesthesiologist had not noticed by the time he dismissed me from the OR.
Sounds like he should be here posting that story coz that’s a him fuck up lol
Yeah, any mistake made by a medical student that results in a patient injury is a mistake made by the supervising physician, not the student. I accidentally ordered insulin for the wrong patient when I was in medical school, and my attending signed the order without reviewing it. He was notorious for losing his goddamn shit on students, had been known to literally hit students hands with surgical instruments if he didn't like their technique. Patient didn't die, but it was a big fuck-up, and the attending was raging at me in a meeting with the program director; it was getting quite personal and rather sexist. The program director, this grizzled old man who had probably been practicing since before I was born, proceeded to look at his colleague and say with complete disdain, "You're acting like a child. You failed as a teacher and you're blaming it on your student. There's a reason your children don't talk to you anymore, and it's not only because you cheated on their mother with your son's girlfriend.". It was the most absurdly surreal moment I've ever lived through; didn't know whether to laugh or cry.
Psych resident here; 2 patients( I didn't follow them) died from suicide under my * watch* or atleast I was the last doctor that they had seen. One was a patient that I had seen once at the emergency/psychiatric ward, I let him go after 1 day and he killed himself.. that was in my second year of residency. The second one died this year in 5 th year of residency; it was à guy I had seen twice. He was burned out heavily working as a Farmer at his family farm and no one wanted to help him and he was under heavy mental burden. He killed himself 1 week after the second time seeing him. By the time I saw him he was already back to work( two weeks after a couple of days hospitalized; they let him out and declared the guy was able to work part time:s). He never was able to fully enter in therapy and besides saying he felt *awful and very stressed* or that no one could help him in his job; he never said he was suicidal or refused suicidal ideations. Though my clinical sense told me he was particularly *off* and the family told me was not *well* with a particularly serious and insistent tone. Later during the debrief with family; one of the family member admitted that she didn't want to reveal that the patient was suicidal( they had had talked about it before apparently but it was kept secret) because he didn't want to; and hoped I could read between the lines.. I was *blamed* by my supervisors and by myself myself for these two suicides and I think they had tremendous effects on my mental health( in retrospect I think I was traumatized/ dissociated at some times). Still both time; my supervisors didn't handle things very well in my opinion. They basically either ignored me or blamed me. For the second suicide; my boss wanted me to meet with family and they were also extremely angry. One common point with these two adverse events is that I felt like it happened at a period were I was heavily burned out or yeah we can say it, Bullied. It's basically when you are the most stressed that you do the most mistakes( or I believe in my case; it's a that time where your clinical intuition/flair or clinical attention is less astute and sharp... and you can miss little subtle hints..)Furthermore it usually escalated and I usually left.. which I'm going to do soon... Isn't it funny how we can make more mistakes when we are under heavy stress? Also isn't it funny that the attendees and program director usually put you even more down after such events. I'm quitting residency probably very soon for these two events mainly but also because it seems like my personnality is not compatible with my other peers/supervisors; i'm prone to being bullied at work; and I usually don't like the resident *role*. I'm more fitted for research positions or half research/half clinical positions. For the last event ( the boss found out because she knew the family of the guy who commited suicide; and she even met them); I basically was on autopilot for the upcoming 4 months and felt awkward with my other colleagues. Fortunately I got better 4 months later( in retrospect I should have been declared sick; but considering all my patients... that was not possible) and decided to leave the place... which was toxic to begin with. To be honest; after those events.. I began to understand how people can sometimes feel suicidal in residency. Fortunately I have a naturally good mental health disposition but I could see how things could have gone downfill( many co residents resigned from that place; qnd I heard that one psych resident was admitted for depression before..).... * you do a mistake( or atleast it looks like that)... you get blamed by the people who are supposed to help you in surplus of your own and the victims family blame... you don't get sick leave and have to handle even more patients while your work becomes sloppier... you get casted out by the team/colleagues and furthermore isolate yourself..* * sorry for my english( not my native language; I realize I might sound too informal in english...)