I have to admit that I feel kind of weird writing my first post ever on the worst mistake of my career.... Anyway I once brainfartet in late shift during training, when a new admission to the ward needed to get some heparin as prophylactic. Syringes were not labeled and usually prepared by the early shift waiting in the fridge for patients bedtime (1 ml indicating 5000 i.e. and 1.5 ml indicating 7500 i.e.). What I think happend was that I ,as before mentioned, brainfarted, not realising that I was not taking Heparin into that syringe, but Insulin (Actrapid). At least this is what I figured out with my Nursinginstructor afterwards. So what happened was that I injected 60 i.e. Actrapid s.c.. We caught the mistake when we found the patient desorientated and sweating. I took her Blood sugar and It read 24 mg/dl. She was given loads of Apple juice with extra sugar and it didn't get better, so we started to stuff her with sweets and breed and the on duty doc gave her a g5 drip. It took the whole night until the effects were wearing off. Patient was fine , I was devastated close to quit the training alltogether. What saved me was that the patient was a nun from the order that ran the hospital and she was also the counselor for us nursing students.This incident never left confines of the ward, and I don't think it should have. Of course today everyone prepares his own syringes, and I label any syringe by copying the names directly off the containers Label also indicating the solution and patients name, I also never use charts were sombody else has written down which patient gets which medication. Furthermore I don't think that it was a newbies mistake and since that stuff might happen to anyone at anytime I am glad I am now aware of the necessity for personal and systematic safeguards against routine. We all mess up, but some of us are lucky enough to work with people that prevent the worst from happening.