Heparin Error - Distraught

Daytonite, BSN, RN · Aug 14, 2005

Many years ago we had a patient who had an Insulin drip going. From what I recall, it was quite a large amount of Insulin in the IV bag because the doc didn't want the patient getting a lot of fluid. It was at a time when IV pumps or drop counters were only put on IVs with Aminophylline, Heparin or Insulin (I'm talking about a med-surg floor). The insulin was mixed into a 250cc bag of saline. The bag was not time stripped (something that was done years ago to kept on eye on whether an infusion was progressing at the correct rate). The nurse following the one that originally hung the bag of Insulin began to worry that the pump was not infusing the Insulin correctly because she later said that it seemed like the fluid level in the bag was going down too rapidly. When the patient had a seizure a few hours later the Insulin was stopped immediately and a blood sugar drawn. The patient's blood sugar was around 20 and two things were noted with the Insulin drip. At some point in time the label had gotten wet, the ink had smeared and the dilution rate of the Insulin to the saline had been difficult to read. Because of that the flow rate on the pump had been changed to the wrong rate. However, it turned out that the pump really was pumping the fluid too fast. We used the pump on another patient later that day where we did time strip the bag and realized in a couple of hours that the pump was pushing nearly double the rate that it was set at.

I don't doubt that the newer equipment used these days is more efficient, but the lesson learned by all was that even though we have wonderful equipment to help us out, for long infusing medicated drips we should always go to the original doctor's order in the chart to verify it, and still keep an eye on the equipment to see that it's working properly. The patient, we were told, had been almost comatose and looked like she was going to code. She was given 50% glucose IV push and had no other seizures. What a scare that was for that patient's nurse. When I heard about this incident I started double checking all medication and IV orders and making sure I was monitoring fluid levels on my IVs very closely.

SharonH, RN · Aug 14, 2005

You are definitely not the only one who has made a serious mistake and in this case, luckily no lasting harm will come to the patient. The good news is that you will be hypervigilant about this in the future. Isn't it good that you have this forum to come to for support? So often in the work setting, there is no support only recrimination and blame.

SmilingBluEyes · Aug 14, 2005

You are not a bad nurse. You are a human being who made a mistake. Own the mistake, don't deny it. Learn what you need to learn from this, learn how to not do it again, then dust yourself off and keep on moving on.
Med errors are devasting, I know. Good luck to you.

amen----good post. Just try to own and learn from the mistake. All of us are human.

dazzle256 · Aug 15, 2005

I am writing because I just made a huge mistake and needed to talk about it. I had a patient receive an entire bag of heparin over an hour. The proper people were notified, the correct reversal drugs given, and the patient is fine - thank goodness. I just feel terrible and I'm almost scared to go back to work. The mistake was caused by a mis-communication between two nurses.
Has this happened to anyone? I realize that I'm not the first to make this mistake and I probably won't be the last, but I just feel like such a bad nurse. This is the first big mistake I've ever made. Ugh.
Any words of advice or experience would be appreciated!
Thanks!

Tulips, the other posters gave some very good advise. I agree it doesn't mean your a bad nurse. The important thing is you learned from your mistake. I've known some very good nurses who have made mistakes.....ie giving blood to the worng person... priming a line with dopamine.

Things happen I'm sorry your feeling so bad.