My biggest mistake, EVER

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    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.
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  3. 4 Comments so far...

  4. 0
    And having done this, you will be ever so much more careful in the future. Thank goodness that it did not harm the patient.
  5. 1
    It takes alot of courage to admit an error and even more courage to share it. Good for you!
    CIRQL8 likes this.
  6. 0
    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!!
  7. 0
    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.