Forgot to restart my patients fluids

  1. I gave an IV push med to one of my patients today and had to unhook them from the continuous lactated ringers infusion to do so. After I was done I forgot to hook them back up to the infusion. It was end of shift and I'm freaking out hoping the next nurse saw and hooked him back up. Has this happened to anyone before if so was it ever a big deal?
  2. Visit daniela095 profile page

    About daniela095

    Joined: Feb '14; Posts: 21; Likes: 5

    34 Comments

  3. by   brownbook
    Yes it's happened. I got into the habit of mentally reviewing my shift as I drive home. From time to time I think of something I may have forgotten to do. I call my unit and let them know. These are "minor" things. The response is usually ....no you didn't forget, or, yeah we figured it out, it's fine.

    Even if it's been a few hours later that you remember it might be worth it to call the charge nurse and let her know. Shows your willing to admit your "error".
  4. by   beekee
    When I was new, the charge nurses all knew my number by heart from the caller ID. I'd forget something and call. Most, if not all, of the time, they figured it out before I called. I'm much better now. No one is perfect. It happens.
  5. by   Been there,done that
    It's a very big deal, it's a medication error. Not clear as to why you had to unhook the main IV. But all of that will come out when you write yourself up.
  6. by   Farawyn
    Quote from Been there,done that
    It's a very big deal, it's a medication error. Not clear as to why you had to unhook the main IV. But all of that will come out when you write yourself up.
    That being said, we've all done it, or something similar.
  7. by   JKL33
    Agree w/ brownbook and yes, make sure to evaluate whether unhooking is entirely necessary or whether a SAS/SMS technique can be utilized instead, which is also good for infection control reasons.

    I wouldn't worry about it. I'd call back and say I realized it on the way home and knew I wouldn't be able to sleep without letting someone know.
  8. by   klone
    I think the bigger question is, why did you have to unhook the IVF to give an IVP?
  9. by   Triddin
    Quote from klone
    I think the bigger question is, why did you have to unhook the IVF to give an IVP?
    Might not have been compatible? Barring the patient being a fresh DKA or active sepsis, I don't think you harmed the patient in any way. I disagree that it is a med error. I would just call the next shift and explain what happened.
  10. by   cleback
    It's a common error. Do you guys do line tracing at hand off? Those error would be caught then. I strongly suggest you incorporate it into your practic.
  11. by   hherrn
    Quote from daniela095
    I gave an IV push med to one of my patients today and had to unhook them from the continuous lactated ringers infusion to do so. After I was done I forgot to hook them back up to the infusion. It was end of shift and I'm freaking out hoping the next nurse saw and hooked him back up. Has this happened to anyone before if so was it ever a big deal?
    It has happened to lots of nurses, and is generally not a big deal. Whether or not its a big deal depends on how long they went without fluids, and why they were getting them. If the infusion was LR at 400 ml an hour for 12 hours for Rhabdomyolysis, or the patient was being aggressively hydrated for burns, and missed 12 hours of therapy, then, sure, it could be serious. Probably not the case, and the PT is probably fine, but food for thought about how to avoid repeating that mistake.

    And, I think I disagree with a prior poster who says this is not a medication error. If fluids are ordered continuously, and stopped prematurely, is that not a medication error?

    And, like others, I am wondering why you had to stop LR for an injection. I suppose it's faster than checking compatibility.
  12. by   offlabel
    Quote from daniela095
    It was end of shift and I'm freaking out hoping the next nurse saw and hooked him back up.
    Well, did you simply call the unit to let that nurse know? Seems like a reasonable thing to do....
  13. by   LovingLife123
    Not everything is compatible with LR. It's not like NS.
  14. by   hherrn
    Quote from LovingLife123
    Not everything is compatible with LR. It's not like NS.
    True enough. Oddly, some are incompatible with NS as well.

    OP?

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