Thanks to everyone who participated in Mishap Mansion and congrats to these draw prize winners:

Winners of Gift Baskets

• Cindy Sellers, Squamish General
• Audra Leopold, RH
• Melissa Tai,  VGH OR

Winners of Coffee Cards

• Heather Everson,  CDC
• Susan Lin, RH
• Helen Bolton, St. Mary’s

Mishaps

Here is a lost of all the possible mishaps that could be spotted in the photos.

• Urine bag on the floor
• Soiled blue liner left on the floor
• Sharp in the garbage
• Latex foley, pt is latex allergy
• Razor on pt’s bed
• Stretcher’s brake unlocked
• Wrong hand restraint
• Restraint tied on the bed/stretcher’s side rails
• Morphine allergy band (pt is not allergic)
• Blood set not used as line
• Blood product label on bag & tag do not match
• Pt. name on tag & blood bag do not match
• IV medication piggy backed together with blood
• Sticker on IV medication is mixed in NaCl, but bag in D5W.
• Nitroglycerine patch is ordered, Fentanyl patch instead on pt.
• No indication when Fentanyl was applied & dosage.
• Pt is allergic to Penicillin. Dr. ordered Penicillin.
• Use of “u” instead of “units” in insulin order.
• Consent is for TKR, Right; post-op x-ray was for THR, right.
• Allergy sheet label is from another patient
• Both BT consent & refusal checked on pre-op checklist
• Pt is on NPO, but there oral medications by pt’s bedside
• Concentrated KCL by pt’s bedside
• Hydromorphone vial, but syringe labeled Morphine
• Specimen tube in the same save a day tray with medications
• Pills inside the dressing kit
• Broken hand sanitizer
• Bottle of poison by pt’s bedside
• Call bell out of pt’s reach
• Tracheostomy tube not secured
• O2 nasal prongs on, but not hooked in the O2 tank
• Breach of privacy: Violent pt form on front of pt’s chart
• Overhead patient lift bar left not completely retracted back (Virtual Tour)
• Cluttered patient room (Virtual Tour)
• Suction placed far away from the patient (Virtual Tour)
• Urinal on chair & suction cart (Virtual Tour)
• Ceiling lift slings all over patient’s room (Virtual Tour)