[jarrn03]

We had the same thing happen a few months ago but we were fortunate that nothing horrible happened. I was so happy that I wasn't working that night. It went through 3 nurses and a CRNA before the night shift nurse found it. Of course it happened to one of our floor nurses daughter.
The nurse that was primarily responsible kicks herself for not listening to her gut. She watched the other nurse struggle to put it in the pump.. our PCN bags are 250cc and the epidural bags are 100.
Like said above it's back to nursing 101!! The 5 rights!
It was definetly a lessoned learned because I think we all are guilty of cutting corners now and then.
Also one time the pharmacy stocked epinephrine instead of ephedrine in our epidural box..luckily the nurse read the label!!

[rph3664]

Hi, everyone! I'm a pharmacist, as my username indicates, and have lurked on this board for quite a while. When I saw this thread, I decided to register and post.

Our epidural bags are 100ml, as are the antibiotic bags, but 90%-plus of our group B strep patients use ampicillin which comes in Add-Vantage bags, which certainly don't look like our epidural bags. Those who are penicillin-allergic get clindamycin, which is pre-packaged and doesn't look like an epidural bag either.

Not working on the floor, I'm quite naive about all the equipment, but reading this thread has me a bit worried!

Hats off to all of you - you have a TOUGH job!

[Suebee6]

Our epidural meds are in glass bottles, not bags at all, no way to mistake them. Plus they are on the other side of the bed by themselves to keep them separate. We do not hang them anyway, the doc does.
How tragic...

[RazorbackRN]

Originally Posted by obrnheather

I don't know if I am 'legally' responsible for actions of LPNs and CNAs - but they do work under my license - I always assumed it was the same thing. If they screw up, it's on my license. Could someone explain the difference to me.

You aren't responsible for the LPN, they have their own license and don't work under yours. They *MAY* work under you as far as rank and supervision, but you aren't legally responsible for the LPN.

You are responsible for the CNA though, because they are unlicensed personnel.

[SmilingBluEyes]

Our epidural bags and abx bags look nothing alike either. PLUS the epidural bag has a BRIGHT PINK label that says: "caution epidural" on it. They really look different. PLUS the abx actually have to be mixed into the bag (there is a little vial attached) before you give them. Hopefully, this is enough to trigger us not to make the same mistake. But I have learned, never to say never and be very careful in all I do. Errors happen; some can be deadly.

[sonja77]

Originally Posted by Suebee6

Our epidural meds are in glass bottles, not bags at all, no way to mistake them. Plus they are on the other side of the bed by themselves to keep them separate. We do not hang them anyway, the doc does.
How tragic...

Same here, and we have a CRNA who hangs the epidural bottles.

[klone]

Oh wow. How awful. Our epidurals are in a syringe that are loaded into a separate pump that looks TOTALLY different from our regular IV pumps. There's no way that could happen in our facility (plus, I don't even TOUCH the epidural pumps, other than to turn them off, so no risk of removing the syringe to show to the pt).

[goats'r'us]

this is an awful situation.

at my old hospital, we only used pre-mixed epidural flasks, that looked different, felt different and were different to anything else. and just to make it doubly clear, a fluro yellow sticker with EPIDURAL INFUSION in big black letters, as well as the date, time, prescriber, and the two nurses who hung and checked the bag was slapped on every one.
epidurals ran through a specific pump that looked different and was different to anything else.
and epidural tubing was also different, it had a yellow streak that ran down it, and that tubing was only ever used for epidurals.
all this contributed to much less med errors, and everyone from the top brass to the new kitchen staff knew what an epidural looked like.

it's no cure, but it sure helped.

[k_cole21]

I thought AWHONN guidelines state that RNs should not "touch" running epidurals for labor patients. I traveled to a place once where the labor RNs hung the meds & set the pumps. I refused to do it. I asked the anesthesiologist to program the pump & he didn't know how!

[Dani989]

It bothers me that RNs pass the responsibility onto the CRNA or MD. They can make a mistake just as easily. We should instead be looking at ways to improve our own practice.