Bad incident while giving Rocephin shot; need advice

[NurseCard]

(This post may get kinda long. I've been trying to figure out where to begin with this story)

Hello all. I'm new to this particular room... I work on a med surge floor that's really a mishmash of all kinds of patients, including pediatrics. Historically, our floor has taken care of patients who just BARELY need to be in the hospital (in other words, not that sick), and the rest have been shipped to bigger hospitals in a larger city one half hour away. Now, our pediatric doctors have decided that they want us to start taking care of more of their patients, that may or may not be sicker than the ones that we have traditionally cared for. They have started doing monthly education seminars for us RN's on the floor.

I feel like I single-handedly put a wrench in the works the other night. I feel like I really put a dent in the confidence that both the pediatric doctors and perhaps even the public at large in the long run, had in the nurses on our floor. Here's what happened:

At 11pm Tuesday night, I took over the care of a six week old baby that had been admitted with fever. She had had a spinal tap done and had been receiving IV infusions of both Rocephin and Ampicillin. However, earlier in the evening before I took her, her IV had came out and no one had been able to get one back in. So, the doctor ordered for her to receive an IM injection of 400mg of Rocephin at 6am.

Well....... for reasons I won't get into, it hadn't been a good night at all. And then at 6:30 am, I was scrambling to get all of my early morning meds passed and my I+O's put into the computer (we have computer charting).

The mom of the baby had refused to let the lab person stick her at 5am for her CBC, because she was flat out tired of seeing her little girl stuck so much, and of course, seeing the little girl in pain from it. However, she had agreed to let the lab stick the baby's HEEL to try to get what blood they needed, and at the same time, let me give her the Rocephin shot... IF we would wait until around 7am to do all of this. I talked to the mom, and we agreed on 0650.

So at 0645, the lab was ready to go in the room and do what THEY needed to do, and of course I needed to go in with them. At this point I was rather flustered because I was behind, I was tired, yadda yadda yadda, but okay, I was ready to go in and give the shot. I had to mix the Rocephin myself in the vial, because the pharmacy had been gone by the time the order had been written... so I mixed it with sterile water (nope, no lidocaine... mistake number 1, I know that now), drew it up in a small syringe, put a 25 gage needle on it, and thought I was ready to roll.

BEFORE I went in the room however, Karen, one of our charge nurses, saw me and said "We're giving that baby IM shots now?" I said "Yeah", she said "So that's Rocephin... does it have Lidocaine in it?" I said "no, just sterile water". Right THEN I felt uncomfortable and my instinct was to hand Karen the syringe and say "Listen, why don't you give the shot, I don't think I'd better." But I didn't do this. Mistake #2.

(note: I HAVE actually given Rocephin IM before, but it's been a long time.)

I went into the room, waited patiently for lab to finish, and then as soon as they were done, I took out my alcohol swab, firmly grabbed the baby's leg, and uncapped the needle. When I uncapped the needle, the mom (who I found out later was actually VERY young, like 18 or 19) started to FREAK OUT. I said "I don't have to put the needle all the way in", though I could have and should have used a TB syringe, mistake number 3. What did I do then? Well, I was trying to make it a quick stick..in, give the medicine, then out. I stuck the needle in and somehow, quite accidentally, DID put it too far in... and the mom started to get more and more upset. Then I tried to push the medicine in... no dice, and the dang syringe EXPLODED and the medicine went everywhere.

At that point... I took the needle out of the baby's leg, wiped her leg with alcohol, calmly placed the needle in the needle boxed, walked out of the room, to the nurses station.... and *lost it*. I mean, LOST *IT*. I thought I had hurt the baby's leg, the mom was crying hysterically AS I WAS WALKING OUT of the room... I just lost it. And when I say I lost it.... I mean.. I was talking in a VERY loud tone of voice about what I had done, what had just happened, and I was about to cry (I in fact DID cry, but I think it wasn't until I was finally behind a closed door).

After giving report and finishing up the rest of my stuff, I came home... and I was STILL crying when I got home because I was afraid that I had hurt that baby, and I was upset because I had made the mom so upset.

This morning I went in to talk to my manager about what happened (who thankfully is a SUPER person and I love her to death), and she said "I'm not upset about what happened!!! Rocephin is a difficult and painful thing to give IM! I'm upset about the way you HANDLED the situation!"

Basically I acted very very unprofessionally... and I already KNEW that.... but apparently, when I was going off about what had happened, the family heard all of it.

Ahem...a little background about me... I have some slight psychological issues, and I'm being/have been treated for them. I have a horrible temper, and I have a strong tendency to want EVERYONE in the area to know that I'm upset about something. I can be calm one minute, and in total hysterics the next. Again, I am taking medication to help with this. =) I don't know how to think long enough to control my emotions long enough to get behind a closed door and THEN let them out.

I also deal with low self-esteem and tend to beat myself up when I make a mistake... and, I don't like to ask for help. Again, demons that I am trying to deal with and overcome.

So... all that aside... I want to make amends and don't know how to do it.

I want to make amends with the doctors. I don't want them to think that we can't take care of their patients, just because of how *I* acted. I'd love to contact the family and apologize, but I feel it inappriopriate. I'm thinking though, about perhaps setting up a time when I can meet with, perhaps just the 2-3 doctors who saw that baby in the hospital, and personally apologize for what happened and let them know that I don't intend for anything similar to happen again, and that I DO want to learn to better care for their patients.

Thanks. Any thoughts are welcome.

[icunrse]

Hi, I am 41 yrs old, a nurse for the past 13 yrs (med-surg/ICU/cardiac). I just an hour ago, received my first Rocephin injection. It hurt like H-E-double hockey sticks!!!!! Ohhhh. It still hurts right now. I just found out I have tonsillitis; and my doc thought I should get it. I wasn't warned that it burns like molten hot lava was being injected. I wish I had! I have given a ton of medications in the past 13 yrs,and I don't recall having given this injection to anyone, but I will most certainly remember the pain and burning associated with it; and at least give a patient a head's up. Not to mention, my glute is beet red around the site, and still hurts to rest on it. I'm fairly certain NO lidocaine was used, because it feels like the needle is still in there. Of course, I had to ask what antibotic shot was being administered by the . She was nice enough, but still. I always tell patients what I'm giving them, even if they're demented. First rule of thumb, if you haven't given a medication ever or in a long time, look it up. Double check your medication, dilution and side effects and any pertinent warnings (such as, this feels like liquid magma going in). Good luck!

[Redhead28]

Been a Pediatric nurse for a loooooooooong time. Rocephin should be mixed with lidocaine to help with pain but it can be mixed with sterile water, so no med mistake. Have to use a larger gauge d/t the thickness when you mix it and try to administer it. Even if you went too deep you can still pull back some and then administer med. We peds nurses seem to travel in packs... ask someone to go with you for procedures. If you don't need help with holding the child, they can help distract the parent. I sometimes ask parents if they would like to step out during painful procedures.

Maybe some anger control or counseling to help you handle stressful situations? Most places have EAP in place, ask HR.

[annabeap, MSN, APRN, NP]

I feel like there should have been more resources on your unit/med room about reconstituting Rocephin- also, it sounds like you didn't have a pharmacist available to refer too, which can leave you hanging.

Also, you try drawing up any med in a 25g needle, and there'll be tough resistance- maybe that's how the syringe exploded. I use 23g at the very smallest for injections.

Our unit has a policy on how many mLs per shot we can inject in a newborn-6mo, etc... I want to say no more than 1ml per injection. And usually I need to grab another nurse to hold/help administer the second shot. We time it so we clean the site, and then on the count of three, give the shot.

I don't think you put a dent in anything except your self-confidence. Live and learn from your experiences and offer the same advice to another nurse that might have a similar situation.

[MommeyRN]

Hey there,

Don't be so hard on yourself......you did nothing wrong, except freak out in the end.

I give rocephin on a weekly basis at least 4-5 times IM. I work in a clinic, so we do IM's daily.

First, you do not have to mix rocephin with lidocaine- its not required. I know that it hurts and it sucks to have to give it, but it is not required. On the contrary, I would not give lidocaine to one of my infants at our practice that was younger than 6 months, simply for the fact that my MD's at our practice stated that its a slight possibility that it could affect their heart rate. (Remember lido from ACLS?....same thing here). Since the CDC stopped requiring nurses to aspirate their IM's, this could possibly happen, and I don't want it to happen to me.

The second thing....You did the right thing by telling her that you "won't go all the way in" with the needle. You can use any length needle, just don't insert it the whole way. I would never ever use a tb syringe for an IM. You don't want the rocephin to be in their subcut tissue.

I gave a hep b last week to a 2 week old, and we used a 1/2 inch needle. I think that if you don't give IM's on a regular basis, it can be a little scary. The problem is trying to get yourself through a moment that makes you question yourself and your practice. The problem is not always your own judgement, but the family member that makes you freak out at the last minute. I would much rather have my child have an IM than an IV, OR a heelstick. So if the thought of you sticking a needle in her childs leg freaked her out, then the heel stick should have been worse- the size of the lancet is HUGE!

Don't be so hard on yourself. Things happen. But in this case, if I was your manager, I would make sure that you knew you did nothing wrong, except doubt yourself. Lidocaine is meant to make it less painful, but, you are a nurse and unfortunately we cause a lot of pain for the better of health.

Keep your head up!!!

:)

[MommeyRN]

Been a Pediatric nurse for a loooooooooong time. Rocephin should be mixed with lidocaine to help with pain but it can be mixed with sterile water, so no med mistake. Have to use a larger gauge d/t the thickness when you mix it and try to administer it. Even if you went too deep you can still pull back some and then administer med. We peds nurses seem to travel in packs... ask someone to go with you for procedures. If you don't need help with holding the child, they can help distract the parent. I sometimes ask parents if they would like to step out during painful procedures.

Maybe some anger control or counseling to help you handle stressful situations? Most places have EAP in place, ask HR.

I agree with everything. I should have read this post before typing my novel of a response! :) Then I could have just typed "Agreed!!" :)

[caroladybelle, BSN, RN]

The big issue was freaking out at the end. That and maybe trying to hard to not hurt the little one.

First, the MD should have ordered the drug mixed with lidocaine. Rocephin shots hurt like heck, even with lidocaine (had a few myself) - but some people are allergic/sensitive to lidocaine. The pharmacy usually calls you to "clarify" the order, especially for a peds pt. Or there is a standing policy.

Second, Rocephin (like some drugs such as IV ativan) is thick - trying to push it through a narrow guage needle will be very difficult and takes extra time. While you think that you are doing the pt a favor by using the narrower needle, you really aren't as it will take longer to inject. And with enough pressure, may pop just as it did.

One of the hardest things to do is not to let the pt/parent see you stress or sweat. Things happen, despite our best intent. But we have to fix it, repair, redo without 'losing it". Everything that you did, I have seen experienced nurse do. The art is in the recovery.