What is the worst mistake you have made or have seen made?

Achoo!, LPN · Apr 22, 2004

I had a patient come in to the clinic with a vial from the pharmacy. She was to get a hepatitis A vaccine before traveling. I looked at the vial, gave it, come to find out it was Hep B. Both the pharmacist and I missed it. Thank goodness it wasn't harmful to the patient, but 2 people missed the mistake. Check check and check again your meds!! :imbar

nurseunderwater · Apr 22, 2004

I saw this thread on the General Nursing board and thought it was interesting.
My worst mistake was dropping a pill on the floor and letting the patient take it. I know I should have gotten a new pill from pharmacy but I didn't want to have to tell the RN and my instructor that I dropped a med. No one found out, but I feel bad about doing something I knew was wrong. I've only in my first semester, so I know there will be more.
I worst mistake I saw was a student who almost administered meds through a patient's trach! Thank goodness our instructor caught her.
What have you done/seen?

10 second rule applies....just kidding :chuckle

UK2USA · Apr 22, 2004

On a night shift in a general surgical ward we had a child who required 4 hourly feeding and not a lot else. The child had a long term hickman, but wasn't receiving any IV meds. At that awful 4 - 5 o'clock period I noticed a rather sleepy student about to attach the formula to the hickman port thinking that it was the gastrostomy tube. I shouted so loud that she jumped and nearly yanked the damn thing out!

orrnlori, RN · Apr 22, 2004

I heard about liquid vitamins meant for a G-tube given intraveniously by a different group from a different school. Nightmare.

twintoo · Apr 22, 2004

As I posted today, I gave a push IV med to a client with a nurse instead of my teacher. That is the worst I have done in 2 semesters.

AmyB · Apr 23, 2004

A while ago I had a patient on TPN that was suppossed to run at 100cc/hr. Despite showing the nurse the correct rate in the orders, it stayed wrong for an entire week. I was rotated to another unit after that, but I bet the TPN went in faster than it should have the entire time.

Another time, I had a patient with a skin graft donor site that was ordered to have a heat lamp applied q2h for 20 min. Again, despite showing the nurse the correct order, she thought the order meant for the lamp to be applied for 2 hours at a time. YIKES!