Forgetting to prime peripheral IV line...

[lpnmommy86]

Hi All! I have been dealing with this in my head all night!! I've searched the internet, but would like your input. If you forget to prime a peripheral IV line that infuse by gravity on a child, what would happen? Severe coughing? Would the child be ok? Any insight will be greatly appreciated.

[JustaGypsy]

There was a case where an adult patient received an injection of 300 ml air via IV during a procedure. The patient coded on and died prior to completion of the procedure. Scary business... Hope your patient is okay, and this I am sure is a lesson you will never forget. (((hugs)))

[SassyTachyRN]

You need to report this as an incident to your manager.

[lpnmommy86]

You can bet it was a lesson learned. I was/am mortified. I will not forget it ever again. Dr was called to the room when this happened. I was not sure what happened at the time. This is the only conclusion I can come too. It was an incident of distraction as well. HR and SpO2 was great. Breathing treatment was done. JustaGypsy thank you for the hug! Definitely needed after that!!!!

[Mavrick, BSN, RN]

This begs the question, what was the volume of the tubing that you used? Every package of tubing states the end to end volume of the tubing. In adults, primary alaris pump tubing has a volume of ~25-30mL.

If you had run whatever you were running on a pump that would have avoided the problem because the pump would have alerted you to air in the line.

After looking it up, I found it is more like 15-18 ml for regular bore tubing and 3 ml for PICC lines.

OP learned a valuable and scary lesson. I learned something too. Keep distractions to a minimum when doing your work.

[Roy Fokker, BSN, RN]

You can bet it was a lesson learned. I was/am mortified. I will not forget it ever again.

Lesson learned is better than none at all.

I work adult ED and occasionally deal with peds - point being? I make it a point of putting some drugs I give adults to on a pump (Vanc, Propofol etc.) When it comes to peds, ALL drugs go on a pump. My hospital works with the Plum+ infusion system, so most drugs are already on the library in the pump - in any case, as part of my practice, when it comes to dosing kids, I'll have another nurse check me. Make sure I have the right patient, drug, dose, infusion rate etc.

cheers,

[SubSippi]

Did you tell anyone about this? I get the feeling that you just kind of left it and hoped nothing happened, because if you had let someone know, you wouldn't be having to come here for answers. An ED doc or other coworker could have given you some info.

[lpnmommy86]

Please see previous post.

[countyERNICU]

Our level I trauma center ED policy is to never infuse anything by gravity on a kid, never.

[rnkaytee]

See, and this is where I get irritated that we're placing a lot of blame on this one nurse. She gets it - it was a mistake, driven by distraction, which is common in health care settings. But why shouldn't this spur on discussion in her facility about Peds IVs being run on a pump and not straight tubing? This could actually lead to good discussions and perhaps changes in her hospital to benefit all patients, not just the ones this RN takes care of.

[Julius Seizure]

See, and this is where I get irritated that we're placing a lot of blame on this one nurse. She gets it - it was a mistake, driven by distraction, which is common in health care settings. But why shouldn't this spur on discussion in her facility about Peds IVs being run on a pump and not straight tubing? This could actually lead to good discussions and perhaps changes in her hospital to benefit all patients, not just the ones this RN takes care of.

It definitely should prompt a discussion on this. In fact, that is exactly what the incident report process is meant to do. Hopefully an incident report (as well as physician notification) was done for this event and the hospital will be able to review it to make sure it doesn't have to happen again.

[rnkaytee]

^^ Absolutely, I've filled out IRs almost exclusively on myself. Sometimes we have to be sacrificial lambs (or at least feel like it!) but I'm a firm believer that every mistake is an opportunity to save someone else from making this same one. I wanted to make the point that many mistakes are system problems, not individual screw ups.

[MunoRN, RN]

This is one reason why I never like to run anything outside of a pump, particularly on kids. There are a couple of things the OP can learn from this; it's certainly possible to start an infusion without realizing the line wasn't primed (I doubt any nurse who works ER/ICU etc. can claim this has never happened to them, and therefore you should always take advantage of something that will catch that mistake for you (a pump).