mistakes in the NICU

  1. 0
    Hello NICU nurses,

    A thread on the general board prompted me to start this thread.

    What are some of the worst mistakes you have seen in the NICU related to patient care???

    A mistake I saw was a nurse put the lines in the wrong chamber after a line change. The TPN and IL rates were reversed. This went on almost all night until the baby became symptomatic and the charge nurse traced the lines and found the problem. When blood was drawn from the UAC the blood had a whitish color. The baby barely survived. Scary stuff!!!!!!!
  2. 11 Comments so far...

  3. 0
    My son in law's mother had a baby at an army post in the state where I work. This WAS several years ago. The baby was a premie, in an incubator. The thermostat on the incubator malfunctioned and it got too hot inside and the baby died. That was told to his mother by the doctors in charge. She went to a lawyer and they told her since it happened on an army base, which is government property that she could not sue.
    It was the only baby girl she ever had. All her other children are sons.
  4. 0
    Our policy states we are not allowed to put medications with feedings. If anyone ever saw pregestimil it looks like lipids if you are not really paying attention. A nurse grabbed it by mistake thinking it was lipids. The poor baby died of cardiac arrest! :-(
  5. 0
    I dont remember anything happening on my shift but once, many years ago someone gave the po iron mixure IV.

    The baby was ok!.
  6. 0
    Originally posted by Teshiee
    Our policy states we are not allowed to put medications with feedings. If anyone ever saw pregestimil it looks like lipids if you are not really paying attention. A nurse grabbed it by mistake thinking it was lipids. The poor baby died of cardiac arrest! :-(
    (Waving hand):imbar Guilty!Only I was giving 22cc of straight lipids PO. I was looking at the syringe and was wondering why it was so....oily. Realized what I had done and stopped it and pulled out as much as I could. He probably got about 6cc. The only effect was some really greasy looking stool. THANK GOODNESS. Now I always look at the label and not the freakin' lid!
  7. 0
    Originally posted by KaroSnowQueen
    My son in law's mother had a baby at an army post in the state where I work. This WAS several years ago. The baby was a premie, in an incubator. The thermostat on the incubator malfunctioned and it got too hot inside and the baby died.
    I have had SEVERAL malfunctioning incubators, fourtunatly without the tragic results.
  8. 0
    Originally posted by dawngloves
    I was giving 22cc of straight lipids PO.
    Better to have it this way around than giving the milk IV.
    We sometimes have pregestimil (that looks exactly like lipids) in syrange pumps.
    I am always terified of mixing up the lines and connecing them wrong- pregestimil IV and lipids PS.
  9. 0
    We had a PICU-experienced nurse come to work at our NICU. She gave 15cc of NaCl (supplement) instead of 0.5cc of NaCl. This was when we drew up our own PO meds from the baby's personal stock bottle in the fridge. Another nurse caught it when she commented that pharmacy didn't send big enough bottles as she was drawing up another 15cc for another baby! As a PICU nurse I don't think she realized that 15cc of anything was just WAY too much for a neonate.

    They then tried to aspirate the first baby's stomach and got some of the NaCl back. The baby came out okay but experienced a Na level of 155 and some gut issues a few days later.
  10. 0
    Another incident...

    We used to have stock bottles of Insulin and heparin flush in the fridge. If we had a sick baby that was getting vecuronium we might have a bottle of that in there too. Guess what happened? Two un-vented babies had their heplocks flushed with vecuronium... with expected results.

    The babies were fine though.
  11. 0
    Just recently we had a baby in the NICU whose UVC line was not in good placement or it punctured the vein...anyway her fluids were going into her peritoneal cavity. This baby was already compromised respiratory wise due to her diaphragmatic hernia, so she was worsened by this occurence.


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