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The 5 most dangerous mistakes you make every day

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Have you ever charted on the wrong patient? Hung a drug that had the wrong name on it, even though it was the drug that you wanted? Double-dosed a patient with metoprolol because you got busy?

Yeah, I thought so. I have, too. Nurses make mistakes every day; most of them we don’t recognize or catch. Thankfully, most of those mistakes aren’t things that are going to hurt our patients. The five biggies, though, can certainly lead to a lot of cleanup and agonizing for you.

1. Not logging out of your computer chart when you’re done.
You’d be amazed at how often people chart under somebody else’s name. In the days of paper charting, it was hard to pick up a colleague’s flowsheet by mistake. Now it happens fairly often—enough that I’m now absolutely paranoid about logging off and double-checking the username at the top of the chart before I start charting.

2. Not double- or triple-checking a patient’s armband.
This is especially important when the patient in question can’t speak up for himself, or doesn’t have family or friends to speak up for him. It’s easy to confuse Mrs. Richardson in 15 and Mr. Robinson in 19, and hang or push the wrong meds. There’s a reason we’re supposed to take our medication sheets into each room and check armbands, and this is it.

3. Not questioning an order you think is a little wonky.
Again, mistakes in ordering—especially when you have order sets all pre-written—is something that happens more frequently now than in the days when doctors had to write orders. When I get a heparin order nowadays, I’m extremely conscious of the fact that our computer contains five different order sets for heparin, for five different specialties. If a heparin drip order looks just a little wonky or unfamiliar at the beginning, you can be sure that the mistake will compound itself the longer it’s allowed to stand.

4. Taking somebody else’s word for it.
This happened to a colleague of mine the other day. In a high-pressure situation, she took somebody else’s word for what medicine was under the light-protective bag, and programmed the pump accordingly. Turns out it was an entirely different medication, and the results, had they not been caught fairly quickly, could have been disastrous.

5. Skipping part of your assessment.
Oh, Lordy. I’ll tell a story on myself here. I was a newish nurse with a very complex neuro patient, and I did a neuro-focused exam. I listened to the guy’s lung sounds, but didn’t spend a whole lot of time on his heart sounds. If I had, I would have noticed the odd squeaking noise that came from a piece of guidewire that had broken off and lodged in one of his heart valves during a diagnostic angiogram. The doc who found it out was one of those perfectly coiffed, unforgiving types, and it’s a lesson I still remember, almost a decade later.

In other words, check yourself before you wreck yourself—or one of your patients.

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Agatha Lellis

Agatha Lellis is a nurse whose coffee is brought to her every morning by a chipmunk. Bluebirds help her to dress, and small woodland creatures sing her to sleep each night. She writes a monthly advice column, "Ask Aunt Agatha," here on Scrubs; you can send her questions to be answered at askauntieaggie@gmail.com.
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One Response to The 5 most dangerous mistakes you make every day

  1. maryamcharles

    I would like to emphasize more double checking what we need to give to our patients especially medication..I had gone through a bad experience few weeks ago when I was in emergency department getting treated for severe abdominal pain..the nurse almost gave me wrong route of administration whereas it should be given Im she make it Iv , luckily I noticed it and asked her again..she even corrected me that im wrong despite knowing im also a staff and work in the same hospital.. after few minutes of agruement, she went checked on the order..what frustrating the manager apologise to me n not her.. a simple mistakes cause everything worse..

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