Different strength baths in unit - safety issue

  1. We had an incident where the wrong Ca++ bath was put on some of the patients machines - 0 instead of 2.5. The patients all were very symptomatic before we figured out the problem. My question is, do any of you keep 0 Ca+ or 0 K+ baths on your unit and add the powder packets of Ca or K? Or do you consider that a dangerous practice and only keep certain strengths on hand? Most of our patients are 2K, 2.5 Ca but we have a couple that differ and we add the packets. Someone told me that should never be done, because it is an accident waiting to happen, which finally did happen on our unit (first time ever) I don't want to over-react, but patient safety is of utmost importance. Any advice?? Thanks
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  2. 9 Comments

  3. by   jnette
    Quote from Robbilin
    We had an incident where the wrong Ca++ bath was put on some of the patients machines - 0 instead of 2.5. The patients all were very symptomatic before we figured out the problem. My question is, do any of you keep 0 Ca+ or 0 K+ baths on your unit and add the powder packets of Ca or K? Or do you consider that a dangerous practice and only keep certain strengths on hand? Most of our patients are 2K, 2.5 Ca but we have a couple that differ and we add the packets. Someone told me that should never be done, because it is an accident waiting to happen, which finally did happen on our unit (first time ever) I don't want to over-react, but patient safety is of utmost importance. Any advice?? Thanks

    Our acid bath (K+2,ca++ 2.5)is pumped upstairs from two huge tanks in the basement and we fill all out jugs with this line.

    However, we do have one patient who needs to be on a zero calcium bath. We have a barrel/drum of zero Ca ++ in the basement which we use to fill his jug with. We used to order the gallon bottles, but after deciding he needed to be on this permanently, went ahead and ordered the barrell. Have never seen the powder packets for Ca++ but we do keep some on hand for the K+.
    But we have many pts. who require a K+3 bath, so we order the barrells as well, and keep the litlle packets to add to a K+2 bath in case our barrell were to run out before the new ones arrive.

    Anytime we have to add something to a jug, we mark it with wide, bright yellow tape around the jug, and note with permanent marker what it contains... ie., K+3.. as WELL AS taping the packet of mix to the jug and the date it was mixed and the initials of the nurse who mixed it. Have never had any problems this way.

    How did your error occur?
    Last edit by jnette on Apr 11, '04
  4. by   AmyLiz
    Quote from jnette
    Our acid bath (K+2,ca++ 2.5)is pumped upstairs from two huge tanks in the basement and we fill all out jugs with this line.

    However, we do have one patient who needs to be on a zero calcium bath. We have a barrel/drum of zero Ca ++ in the basement which we use to fill his jug with. We used to order the gallon bottles, but after deciding he needed to be on this permanently, went ahead and ordered the barrell. Have never seen the powder packets for Ca++ but we do keep some on hand for the K+.
    But we have many pts. who require a K+3 bath, so we order the barrells as well, and keep the litlle packets to add to a K+2 bath in case our barrell were to run out before the new ones arrive.

    Anytime we have to add something to a jug, we mark it with wide, bright yellow tape around the jug, and note with permanent marker what it contains... ie., K+3.. as WELL AS taping the packet of mix to the jug and the date it was mixed and the initials of the nurse who mixed it. Have never had any problems this way.
    Our unit does the same thing. We have 2K+, 2.25Ca++ pumped through the wall. We use the gallon jugs though for everything else. And yep, we mark the jugs that we add mix to with black marker (big letters, etc).
  5. by   jnette
    Quote from AmyLiz
    Our unit does the same thing. We have 2K+, 2.25Ca++ pumped through the wall. We use the gallon jugs though for everything else. And yep, we mark the jugs that we add mix to with black marker (big letters, etc).
    We used to just do the black marker thing, but found that the wide band of yellow tape in ADDITION was even better... made it far more noticable. And anytime we add a packet of any kind, we are required to attach the empty packet to the jug with time, date, and initials, (kind of as you would add a sticker to an IV bag that you added something to)..as it is still considered a med.

    We have about 6 patients or more who are on K+3 baths, so we keep these larger jugs filled, taped, and marked, and ...... carry them up from the babsement every day... that's where the drum is kept that we fill them from.

    Can't wait for our new clinic... no more basement... no more carrying up bags of bicarb, , 30 pound jugs of K+3, and all those boxes of saline and dialyzers from the basement !!!

    Woohoooooooooo !!!

    So AmyLiz.... how's it GOING !!!??? Are you learning much? Are you liking it so far???
  6. by   AmyLiz
    It's going pretty well. I'm learning so much, it's incredible! So far, so good! I still have 1.5 weeks left in the classroom part of orientation, but I've done some clinicals too while we're "book-learnin" The week after next will be full-time with a preceptor, so I'll let you know how that goes.
  7. by   Juanay
    Jnettte,
    The first unit I worked in mixed special baths ALL the time.
    Our standard bath was 2.0 K+/ 2.5 Ca. We had pt.'s ranging from 0K to 4.0 K+ and from 0 Ca to 5.0 Ca. It was horrible! In the 2 years I worked there we never had a problem. The RN's mixed the baths. The jugs had to be labeled with a special label that verified the original bath and the additive. Then the bath was verified by 2 personel prior to pt tx. When I started traveling last year, my first assignment was in Memphis, RCG unit. All pt 's were on standard bath. 2.0K+/2.5 Ca. This was a very large unit of 36 stations and NO special baths. Nephrologists said it didn't make that much difference.
    In the unit I work in now, also RCG unit, the standard bath is a 3.0K+ 2.25Ca. We have several pt's on special 2.0 K+/2.5Ca baths and 3 pt.s on 2.0K+/3.0Ca. All of these come premixed and we just connect the jug to the machine.
    Juanay
  8. by   jnette
    Quote from Juanay
    Jnettte,
    The first unit I worked in mixed special baths ALL the time.
    Our standard bath was 2.0 K+/ 2.5 Ca. We had pt.'s ranging from 0K to 4.0 K+ and from 0 Ca to 5.0 Ca. It was horrible! In the 2 years I worked there we never had a problem. The RN's mixed the baths. The jugs had to be labeled with a special label that verified the original bath and the additive. Then the bath was verified by 2 personel prior to pt tx. When I started traveling last year, my first assignment was in Memphis, RCG unit. All pt 's were on standard bath. 2.0K+/2.5 Ca. This was a very large unit of 36 stations and NO special baths. Nephrologists said it didn't make that much difference.
    In the unit I work in now, also RCG unit, the standard bath is a 3.0K+ 2.25Ca. We have several pt's on special 2.0 K+/2.5Ca baths and 3 pt.s on 2.0K+/3.0Ca. All of these come premixed and we just connect the jug to the machine.
    Juanay
    Interesting !

    I always thought the 2.0 K+ was pretty standard... never heard of 3.0 K+ being standard, as most of the pts. struggle to keep their K+ levels down as it is... hmmmmm.


    We keep most of ours on the standard baths as well, unless their labs show a specific problem with their K or Ca, then we make a change and keep our eyes on lab results.
  9. by   Robbilin
    How did your error occur?[/QUOTE]

    Someone apparently unloaded one carton of the 0 Ca++ baths and mixed them with the 2.5 C baths accidently. Then when they got the stations ready, grabbed the wrong baths without reading the label, assuming they were stocked correctly. And since almost all the patients get the same bath, the nurse hooking up that patient didn't look at the bath strength. So like 3 people "assumed" everything was correct. Not a good day.
    We generally take a red marker and label the jugs anytime we add packets, but never taped the packet to the jugs. I like that idea. Plus we never do any witnessing of any of that, that might be another good idea. Anyone on our unit mixes - RN, LPN, Tech.
  10. by   jnette
    Quote from Robbilin
    How did your error occur?
    Someone apparently unloaded one carton of the 0 Ca++ baths and mixed them with the 2.5 C baths accidently. Then when they got the stations ready, grabbed the wrong baths without reading the label, assuming they were stocked correctly. And since almost all the patients get the same bath, the nurse hooking up that patient didn't look at the bath strength. So like 3 people "assumed" everything was correct. Not a good day.
    We generally take a red marker and label the jugs anytime we add packets, but never taped the packet to the jugs. I like that idea. Plus we never do any witnessing of any of that, that might be another good idea. Anyone on our unit mixes - RN, LPN, Tech.
    That's why I like this BB.... always something to learn from others !
  11. by   Farkinott
    Any additive to a regular bath is double checked by 2 RN's and a highly visible orange additive label is put on the bottle. It would truly take a super numbnuts to give the additive bath to another client!

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