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Procedural error- bloodborne exp issue?



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Nov 23, 2008 12:17 PM

Procedural error- bloodborne exp issue?

by mnm4u

I work in a small community hospital here in Florida. The other day 4 of us were "on assignment" placing PPD's for the staff. This was a full day event- doing over 200 for the day.

I just found out that my friend apparently made a mistake. She went to inject the serum under the skin and noticed that needle moved out of the skin and consequently did not administer enough. So she withdrew the needle from the skin, then used the same needle to draw up more serum from the multi dose vial- then continued on. Therefore potentially exposing everyone else that follows with some blood borne pathogens, correct?

She is normally a very diligent, focused nurse. I know this was just a "slip". Do you think she will be disciplined? If so, what can happen? We are testing those possibly affected. An incident form was filled out and the hospital administrators are investigating. Thoughts?


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3 Comments
No. 1
Old Nov 23, 2008, 01:03 PM

Default Re: Procedural error- bloodborne exp issue?
Holy Cow...that is scary! I am sure she is a good nurse, but I cannot imagine how I would feel if I were exposed that way, I think I would want her to be disciplined if my life were possibly on the other end. I really hope that it works out for everyone...
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No. 2
from iluvivt
Old Nov 23, 2008, 08:18 PM

Default Re: Procedural error- bloodborne exp issue?
At least she realized the error and the hospital can rectify it as much as possible. I think the nurse will be counseled in part due to the added expense to the hospital as well as the potential exposure to the employees. In the future all doses should be drawn up from the vial at once. There is not a unit dose available for this drug at least the last time I checked.so a multi-dose vial is used. All doses should be drawn up and what is not used for the day should then be discarded. That way,a nurse will never have to enter the vial again,just grab the pre-filled syringe.
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No. 3
from Jolie
Old Nov 24, 2008, 07:51 AM

Default Re: Procedural error- bloodborne exp issue?
I am thankful that the nurse admitted her error. It would have been easy to keep it to herself, and no one would have been the wiser. That shows courage and professionalism on her part.

Was the employee who was "restuck" contacted for testing? Were detailed records kept so that it will be possible to identify the employees who received injections from that vial after the incident occurred? If so, have they been contacted to receive testing, counseling and preventive meds?

I'll be interested to see how this is handled by the institution.
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