I think it would be beneficial to us all to share stories of mistakes we have personally made, or almost made, or stories we have heard or seen of other nurses making mistakes. I don't know about all of you, but I know I learn best from mistakes. Something about that scare tactic drills the lesson in a little deeper than if someone was just to say "next time you should do it this way". I'm a brand new RN so fortunately I personally don't have any stories, but I have heard some good ones from experieneced RN's. I am off orientation in two weeks, so since I've been an RN I've always had someone double checking everything. I did have one close one though.
Our patient was taken to OR right before shift change. He was also a new admit from ER for Auto ped accident. In report we heard his lactate was high and his blood pressure was on the soft side. They had tried getting access but he was a hard stick, they even used the site rite ultra sound machine to try to get a peripheral and had no luck. He had one IV the paramedics had managed to get. His electrolytes were also thrown off. Phos was low, K was a little low, and he was going to need calcium. So we knew he was going to need some fluid resusitation and more than one IV for access. Anesthesia had said they would put a central line in our patient while he was in OR.
Patient is in OR and I started pondering the idea of what if he comes back really sick from OR. I asked my preceptor and the other nurses in our pod what they would do if he comes back unstable.Say they get the central line in but no chest x-ray had been done yet to verify. We know he is a hard stick, say our efforst are just as bad. Would they go ahead and use the central line before verification? Everyone agreed, if he was unstable enough YES they would use the central line.
Patient comes back from OR, Line is in, vital signs appear stable and he still has vecuronium on board so he isn't moving anything. I look at his central line to transduce a CVP from and there is a wierd dead ender on it, my preceptor recognized it to be the hub of the wire they had totally forgotten to pull out and she took it out. A fair amount of blood came out but we didn't think too much of it, we hooked up the CVP and a huge wave form appeard. It was definitely an arterial wave form. Chest x-ray by this time had been up and gotten verification of placement. It was in the CAROTID ARTERY! The doctors immediately came to bedside to pull it out and the patient fortunately didn't stroke from it and ended up being fine, but it was scary to think we had all talked about transfusing something through that line if need be. To think if we had given anything through there it would have gone straight to his brain.
Lesson for me learned is never trust any line placement until it at least has been transduced. But ALWAYS get chest x-ray first.
