I am a relatively new pediatric nurse. I just have a question about an incident that happened the other night at work. While changing a PICC line dressing on a 1 year old (yes I had help to hold the pt), the line came out maybe 1/2inch. I kept my field sterile and placed a sterile dressing on top, as I did not want to mess with the line further until the dr was notified. (the old dressing at this point had been removed). I notified the charge nurse and a call to the dr. was placed to get a CXR to look at line placement. The ER dr called me (our drs usually aren't in house at night) and told me that the line was "not in the correct placement." I specifically asked her if she recommended using the line, and she told me no. I informed the charge nurse and a call was placed back to the pt's primary dr to let him know. He didn't seem too concerned and told me that I could go ahead and use the line. First off, I felt very uneasy about this due to the fact that the ER dr said do not use the line. I told my charge RN what the dr said and she felt the same way. She told me directly NOT to flush the line or even mess with it.
She told me at this point it would be wise to start PIV to give the Vanc until the dr could physically come look at the CXR in the AM. She started the PIV and the dose was given through that. When the dr came in the next morning he was livid. Needless to say, I got a call from my supervisor saying that they had to take the line out because it wasn't flushing or drawing since I didn't flush it on my shift. (I don't know how to feel about that either). She also said that my placing a tegaderm without a biopatch could have potentially infected the site..again I'm not sure but it doesn't sound right to me.
My questions are:
Was I right in placing the PIV (I went to the charge nurse and this is what I was basically told to do)? It just made me nervous thinking the dr that actually saw the xray told me not to use it. What if the pt had received the Vanc and it infiltrated?
Is this something that I could potentially be fired for or would it be more of a "correction" type issue?
Would the board of nursing back me on my decision in this case?
I am just so scared about all of this. I did what I was told to do and then I got in trouble. I know ultimately it comes down to MY decision, but I took it up the chain of command (the charge nurse didn't call the supervisor at this point to ask her opinion). I just didn't feel quite right going with what the dr told me to do if that makes sense.
Thanks for listening and thanks in advance for the advice.
Ah, the ages old nurse in the middle and getting all the blame scenario.
I would have done the same as you did. I would have probably used the biopatch, although to be honest, if you maintained your sterile field the chances of infection from not using one, especially given that the dressing was likely to be removed in the near future and replaced if the line needed to be advanced, were probably slim.
As far as it not working anymore, was that before or after they tried to manipulate it back into place? If they just left it in the same place, I would suspect that that could be the reason why it wasn't working, given that the ED doc said it was not in proper placement. Either way, the doc who actually looked at the CXR for placement is the one whose opinion I would defer to. Unless the other doc viewed the film from home before giving the go ahead to use the line...but I would hope he would have told you that he had looked at it before making the decision.
In this situation, it might be in your favor to drop an email or other written account of what occurred to your NM, in an emotionless and factual way. Like instead of saying "dr. was angry" put something like "MD objected to the decision to not utilize PICC line despite prior orders from ED MD to not use line until CXR viewed by primary to maintain patient safety secondary to questions regarding placement of PICC." Be sure, if you do do this, to include all steps that you took regarding the decision and to maintain patient safety in this manner.
Ultimately, yes, the kiddo did get another line. However, they also got their abx into them, and in a way in which there was no question as far as delivery into the right place. We are in no position to judge the risk vs. benefit of what the ultimate outcome was, which is why you deferred to a MD and then used that information to make your final decision, and why the docs need to take it up with each other if there's a discrepancy in opinion.
document. thats what nurses do. if you spoke to the er doc and he said " do not use"....write the order. it covers you and it puts the " conflict" where it should belong ...which is between the 2 docs. unless the doc who didnt view the cxr has telepathy....he had no business giving you the ok, unless he had a written hardcopy report from radiology that said it was in an acceptable place.
but...if no hardcopy tenative report was given from radiology....then you did the right thing. i do have a question...why did you contact 2 docs? after you got the order to not use it...you really shoulda stopped there.
drop an email to your boss. tell her as a courtesy you notifid the primary md of the misplacement. and that you felt that you were placed in a disagreement that belonged between the 2 md's.you erred on the side of caution....so....it is ok.omg.....all this drama over a line? dont let them blow this even more out of proportion than it already is. you erred on the side of caution. the only question i have is: most piccs have been primed with heparin after the docs finish placing it. so....it should have been ok even with you not flushing it for one 8 or 12 hour shift.
ah, the ages old nurse in the middle and getting all the blame scenario.
i would have done the same as you did. i would have probably used the biopatch, although to be honest, if you maintained your sterile field the chances of infection from not using one, especially given that the dressing was likely to be removed in the near future and replaced if the line needed to be advanced, were probably slim.
as far as it not working anymore, was that before or after they tried to manipulate it back into place? if they just left it in the same place, i would suspect that that could be the reason why it wasn't working, given that the ed doc said it was not in proper placement. either way, the doc who actually looked at the cxr for placement is the one whose opinion i would defer to. unless the other doc viewed the film from home before giving the go ahead to use the line...but i would hope he would have told you that he had looked at it before making the decision.
in this situation, it might be in your favor to drop an email or other written account of what occurred to your nm, in an emotionless and factual way. like instead of saying "dr. was angry" put something like "md objected to the decision to not utilize picc line despite prior orders from ed md to not use line until cxr viewed by primary to maintain patient safety secondary to questions regarding placement of picc." be sure, if you do do this, to include all steps that you took regarding the decision and to maintain patient safety in this manner.
ultimately, yes, the kiddo did get another line. however, they also got their abx into them, and in a way in which there was no question as far as delivery into the right place. we are in no position to judge the risk vs. benefit of what the ultimate outcome was, which is why you deferred to a md and then used that information to make your final decision,
and why the docs need to take it up with each other if there's a discrepancy in opinion.
I didn't mean that the line would be directly in the lung. Isn't a complication of insertion of one of these lines a pneumothorax? So if the lung could be punctured upon insertion, doesn't it also follow that the lung could be affected if the line is moved around after insertion and placement is not verified? If placement isn't verified, isn't 1/2 an inch (for an infant) enough movement for it to possibly be in the vein leading to the lung rather than the superior vena cava?
I've never seen this happen or anything...it just seems like it could happen. Which is why it would be a bad idea to put fluids through that line...unless i'm making ridiculous leaps of logic...but i thought i remembered hearing this stuff in school...
Also, couldn't movement of a PICC cause cardiac arrythmias?
mama_d, BSN, RN
1,187 Posts
Ah, the ages old nurse in the middle and getting all the blame scenario.
I would have done the same as you did. I would have probably used the biopatch, although to be honest, if you maintained your sterile field the chances of infection from not using one, especially given that the dressing was likely to be removed in the near future and replaced if the line needed to be advanced, were probably slim.
As far as it not working anymore, was that before or after they tried to manipulate it back into place? If they just left it in the same place, I would suspect that that could be the reason why it wasn't working, given that the ED doc said it was not in proper placement. Either way, the doc who actually looked at the CXR for placement is the one whose opinion I would defer to. Unless the other doc viewed the film from home before giving the go ahead to use the line...but I would hope he would have told you that he had looked at it before making the decision.
In this situation, it might be in your favor to drop an email or other written account of what occurred to your NM, in an emotionless and factual way. Like instead of saying "dr. was angry" put something like "MD objected to the decision to not utilize PICC line despite prior orders from ED MD to not use line until CXR viewed by primary to maintain patient safety secondary to questions regarding placement of PICC." Be sure, if you do do this, to include all steps that you took regarding the decision and to maintain patient safety in this manner.
Ultimately, yes, the kiddo did get another line. However, they also got their abx into them, and in a way in which there was no question as far as delivery into the right place. We are in no position to judge the risk vs. benefit of what the ultimate outcome was, which is why you deferred to a MD and then used that information to make your final decision, and why the docs need to take it up with each other if there's a discrepancy in opinion.