made a mistake...

Nurses General Nursing

Published

i had to complete peritoneal dialysis for a patient twice a shift. order stated 2000cc from a 2500cc bag.

normally, a prompt would show up if it was for a pill. for example:

--"READ THIS: only administer 12.5 mg of 25 mg"--

the offgoing nurse told me what the pt likes to watch, eat, favorite hobbies, etc... BUT failed to mention "only give 2000 of the 2500 bag". keep in mind, we do have a 2000cc bag and they BOTH can be scanned interchangeably. i have no idea why/how? so i figured, IF IT SCANS... nothing more to it. i didn't notice the order, as i never experienced this.

my fault... for not reading the order. but how do i go about resolving this? as so it would NEVER happen again. i had to file a "risk" report...

i called the MD and no orders were given. they told me the order was because the pt was retaining fluids. i input 2500 and received 2300, twice. other times, i had patients retain more than this and no such order was given... so i didn't even bother second guessing. i am going back again... hope i didn't injure the person.

I gotta say, I was nervous clicking on this topic when all I could see was the title and your username...

Specializes in Emergency, Trauma, Critical Care.

I have to agree...you might want to change your username.

As long as you informed the MD. And no further actions were required, he will have dialysis again shortly. But ill bet after that experience you will carefully read orders. Sometimes these things help us be better nurses and stop us from rushing and making assumptions. ..all good things.

Specializes in ORTHO, PCU, ED.

Why on earth would you want that username[emoji15]

Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

Change your username please!

You asked how to resolve this I'm assuming as in how not to have this happen again?

Always read the order. Never take the word of a coworker.

Specializes in Nephrology, Cardiology, ER, ICU.

Staff note - staff has changed user name.

The off going nurse did not have to clarify the order for you.

Just because it scanned, it does not mean the dose is correct. That is up to the nurse to decide.

"order stated 2000cc from a 2500cc bag. " The way to resolve this? ... read the order.

Specializes in Pediatric Critical Care.

Wait guys I missed it! What was the old username!???!

i had to complete peritoneal dialysis for a patient twice a shift. order stated 2000cc from a 2500cc bag.

normally, a prompt would show up if it was for a pill. for example:

--"READ THIS: only administer 12.5 mg of 25 mg"--

the offgoing nurse told me what the pt likes to watch, eat, favorite hobbies, etc... BUT failed to mention "only give 2000 of the 2500 bag". keep in mind, we do have a 2000cc bag and they BOTH can be scanned interchangeably. i have no idea why/how? so i figured, IF IT SCANS... nothing more to it. i didn't notice the order, as i never experienced this.

my fault... for not reading the order. but how do i go about resolving this? as so it would NEVER happen again. i had to file a "risk" report...

i called the MD and no orders were given. they told me the order was because the pt was retaining fluids. i input 2500 and received 2300, twice. other times, i had patients retain more than this and no such order was given... so i didn't even bother second guessing. i am going back again... hope i didn't injure the person.

Peritoneal dialysis can be a beast ....

If you can print out the order (if you are on EHR) I would suggest you do that.

Take the order to the room and check off on the paper everything so you know you verified. Of course it would be somewhat double if you scan in the bag but sometimes you can have extra order for peritoneal dialysis like not to dwell the whole bag, or to add medication to the bad (if you have to do that read your P&P because it is not just using an alcohol swap and stick the needle through the port...).

In any way, if you are doing peritoneal dialysis and the pat is not returning fluid but is overloaded it is a problem and you need to discuss with the MD. There are different solutions and concentrations that will result in different pull of fluid.

Is this related to the patient you had who had a mistake and died in December or is this a different patient? Is this patient still ok or did he die too? I think all you can do if this is a new situation and a different patient is to learn from it by not making any more mistakes like this! be sure to read orders carefully and be sure when you take out meds you check them carefully against the orders or the medrec sheet, whatever you're using. Everyone makes mistakes but if you're a new nurse and this is the second patient that has died under your care you are not likely to be in nursing for long. Unless maybe this patient turned out fine?

Is this related to the patient you had who had a mistake and died in December or is this a different patient? Is this patient still ok or did he die too? I think all you can do if this is a new situation and a different patient is to learn from it by not making any more mistakes like this! be sure to read orders carefully and be sure when you take out meds you check them carefully against the orders or the medrec sheet, whatever you're using. Everyone makes mistakes but if you're a new nurse and this is the second patient that has died under your care you are not likely to be in nursing for long. Unless maybe this patient turned out fine?

different patient... the patient that expired, i did EXACTLY what the MD ordered. it was 1 of those instances where a procedure can potentially kill the person or keep them alive for another month or 2... the patient was do not resuscitate status. guess that's why nobody gives an F. i was only task running that shift. come to think of it, that's all i ever do nowadays. i am always dumped on with unsafe assignments. i reported it this time. looking for a new job, also.

the other person wasn't harmed, MD said don't worry about it, and was discharged.

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