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Had a horrible weekend...

Med-Surg   (408 Views 4 Comments)
by carberrylane carberrylane, ASN, BSN (New Member) New Member

594 Visitors; 3 Posts

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So I had a horrible weekend... just so much and understaffed. I made a huge mistake and hung central line potassium on a peripheral line patient. It was ordered that way and the pharmacy sent it up that way and I gave it. I read our policies on it and there to me it was a tad confusing. Anyway, I am not sure if this is a big deal or not but I've never made an error like this before.  After about 10 mins the pt complained of pain and I stopped it. The pharmacy called the next morning and made it sound like it was the previous shift pharmacists' fault but I knew better and should have double checked. She was fine.. it didn't effect her and they ordered oral K for her after that. I just feel so guilty. How do you handle situations where you make mistakes? I want to learn from this and will always double and triple check everything and call when I don't know something for sure.. Have you ever made a mistake like this before? Thanks for any input!

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0.9%NormalSarah is a ADN, RN and works as a MICU RN.

345 Visitors; 78 Posts

Just sending hugs your way. I am a new nurse and don’t have any nurse mistakes under my belt yet, but I made mistakes back when I worked in dialysis as a tech and it’s definitely embarrassing and scary, even when your patient didn’t suffer a poor outcome. I guess it’s just one of those things that you get over in time, it stings less but the lesson is always there in your mind. Sounds like your patient was ok, and I’m sure you won’t make that mistake again. 

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greenerpastures has 5 years experience.

5,619 Visitors; 190 Posts

It's a lesson you'll never forget.  Potassium can cause extreme extravasation if it gets outside a vein.  Central line concentrations tend to be higher than peripheral line concentration bags (example: KCL 40meq in 250mlNS for central, but diluted in 520ml for a peripheral). You recognized the pain and stopped the infusion. You learned something from it.  The patient wasn't harmed.  My advice, pass your experience on to new nurses so they don't make the same mistake.  Second piece of advice, ALWAYS double check anything you don't make yourself.  Pharmacists make mistakes, people who fill the pyxis/omnicell make mistakes, everyone MAKES mistakes.  I've found more than 10 discrepancies in my 5 years...protect your license. 

Above all else, forgive yourself. You made a mistake. You learned from it. You won't make the same mistake twice. 🙂

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3,924 Visitors; 377 Posts

It wasn't just your mistake, it was the MD's and the pharmacy's too. We are the last person before the medication gets to the patient but its on the team to catch these things. At my hospital any thing that requires a central line has a red sticker on the package that says central line only. Might be something to suggest. Its a mistake anyone could make. 

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