Scariest thing you have found - page 2

What is the scariest thing that you have stumbled across after following someone else? I found that a Dopamine drip had been started and left on all weekend on my medical floor that had staffing... Read More

  1. by   zudy
    A tube feeding that was supposed to going to the peg going into the subclavian. Actually, have seen this more than once.
  2. by   boopchick
    IVF infusing into JT rather than midline???!!! This floored me!
  3. by   Nurse Ratched
    Not that there is ANY excuse for not asking when you don't know something, but this thread is another great reason why nurses should not be forced to float to unfamiliar areas.

    I've run into an IV (hepwell, actually) inserted backwards, and when I was an aide, I once turned a contracted, bedbound pt only to discover a rectal thermometer (we still used glass) still inserted. Fortunately, nothing got perforated.
  4. by   shoelace
    Originally posted by zudy
    A tube feeding that was supposed to going to the peg going into the subclavian. Actually, have seen this more than once.
    You're kidding me.
    Did they live?
  5. by   VickyRN
    A tube feeding that was supposed to going to the peg going into the subclavian. Actually, have seen this more than once.
    This happened last summer at a large teaching hospital. New grad working in an ICU setting. Error was caught also immediately by the nurse's preceptor. Tragically, the patient (a 6-year old boy) died. Day afterward, every single feeding pump in the whole facility was removed and kangaroos brought in (has tubing too big to be inserted into an IV by mistake).
  6. by   ERNurse752
    Originally posted by VickyRN
    This happened last summer at a large teaching hospital. New grad working in an ICU setting. Error was caught also immediately by the nurse's preceptor. Tragically, the patient (a 6-year old boy) died. Day afterward, every single feeding pump in the whole facility was removed and kangaroos brought in (has tubing too big to be inserted into an IV by mistake).


    Oh my God...that's horrible...for everyone involved.
  7. by   hoolahan
    At line change, the nurse hung two dopamine drips instead of the dopa and dobutamine. The drips were double concentrated because the pt had renal insuff. So the dopa was supposed to be like 2.5cc/hr or 2 mcg/kg/min and the dobut was running at 10 mcg/kg/min. So when she hung the dopa instead of the dobutamine, the pt became very tachy at change of shift. She was calling doc and they were initiating bolus of cardizem and she was readying a drip when I discovered what she had done.

    The kick in the butt was, the pt son was there, and he was praising her up and down to me about how she had picked up on her father's change in condition and acted so quickly on his behalf, he was so impressed w the care his father got. Ha!!

    This man was a dean of a lg university, and he offered her a BSN education for no cost!! Do you believe she had the audacity to accept it???? I would have been so embarrassed, I could never in good conscience have accepted that knowing that my error could have killed the man!!! Some people have no shame!!
  8. by   obeyacts2
    My mom was admitted to stay the night after a mod radical mastectomy. Yes, around here mastectomies are same day surgery Anyway her O2 sats went alittle low during surgery and they decided to abserve her for the night. Anyway. the fact that she was diabetic was missed by staff....buried in her chart maybe? She was given drugs that are contraindicated for type2 diabetics (med conflict) Luckily she is aware and a former nurse and was able to spot the mistake...the discharging nurse was horrified.....never did find out what happened .....Sugar went way up as they didnt give the diabetic tray eitherrr..... Scary



    Laura
  9. by   Rena RN 2003
    see, it's stuff like this that scares the beejeebies out of me. surely none of the nurses involved in these situations (other than maybe not hanging the IV antibiotics) did these things on purpose. i realize it's better to know what you don't know in certain situations but i'm scared to death that i'm gonna miss something.
  10. by   Jay-Jay
    <deep breath> Okay, true confession time here... had a pt. on a PCA pump. The pharmacy doubled the concentration of the drug (dilaudid), and I did not get an update from the doc. There MAY have been a warning on the cassette, or on the bag the cassette was in, but the pt's husband removed it from the bag for me. Anyway, I missed it. So did several other nurses. Pt. c/o ++ drowsiness, but STILL rated pain at 6/10. Caught the mistake next time I changed the cassette (three days later.) By this time, the pt. was so accustomed to the dose, that we left things the way they were, just did some reprogramming of the pump so the concentration matched what was actually on the cassette.

    Three days later, pt. was admitted to palliative care unit of hospital, with uncontrollable pain. BUT I still get cold shivers thinking of the possible outcome....

    Needless to say, the management VERY carefully reviewed and revised their procedures for pain pumps, as well as giving the nurses responsible some heavy-duty education to make sure this doesn't ever happen again!

    Scariest thing I've run across so far that I wasn't responsible for? Found 2/3 & 1/3 hanging with a blood transfusion, while working agency! And it was a regular staff nurse who was responsible for the error, too!
  11. by   atownsendrn
    Was working as overhouse supervisor one evening. Had insulin drip on the floor - had just mixed the bag about 45 min earlier when nurse caring for patient called be for another drip. I asked what had happened to the first one. Nurse replied "it's out" So I went to the floor. They had ran the insulin drip in at 55units/hour instead of 5.5 units/hour.

    Some "crazy" things I've seen..................

    Recieved pt from ER into ICU - was told in report that pt had 3+ pedal pulses. Pt still had on shoe and had a right BKA. So much for those assessment skills.

    Recieved pt from EMS with splint on left arm with reported obvious deformity. It was the right arm that had the obvious deformity (and no splint) Pt said "I didn't know why they put the splint there but I figured they knew what they were doing"
  12. by   Liddle Noodnik
    Originally posted by Jay-Jay
    Found 2/3 & 1/3 hanging with a blood transfusion
    What's this mean please?

    Probably so obvious...
  13. by   Jay-Jay
    Zoe, you NEVER EVER hang blood with anything but N.S! It's just not compatible, and will cause the cells to lyse or maybe even coagulate. Luckily, the 2/3 & 1/3 was not actually turned on to run with the blood, but had been used for flushing at the end of the transfusion.

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