My biggest mistake, EVER

  1. Just the other day I took over operating the cell saver from another employee. After running my final bowl of RBC's, I was just sitting there, monitoring the blood loss, when I suddenly noticed that I washed the previous bowl with LR rather than NaCl! It had been 15 or 20 minutes since infusing the blood. I literally got nauseated and my heart rate must have climbed to 120! I immediately informed the CRNA. She reasuured me that no harm would come to the patient.

    Boy, do I feel stoooopid!

    I have never made such a serious error.
  2. Visit CIRQL8 profile page

    About CIRQL8

    Joined: Apr '04; Posts: 296; Likes: 94
    Service Line Faciliatator, Robotics and surgical urology.; from US
    Specialty: 13 year(s) of experience in Only the O.R. and proud of it!


  3. by   rn/writer
    And having done this, you will be ever so much more careful in the future. Thank goodness that it did not harm the patient.
  4. by   passionate
    It takes alot of courage to admit an error and even more courage to share it. Good for you!
  5. by   CIRQL8
    Thanks, passionate!! I apprecite the words...

    Apparently, my error should only change the oxygen-carrying capacity of the RBC's in that last re-infused unit (at worst). At best, nothing. As LR is routinely used IV (as we all know), that is OK!!
  6. by   passionate
    My biggest mistake? Dropped the skull flap. That night I learned bone can be autoclaved. So, I guess it wasn't my worst mistake ever. That is probably yet to come.