Heparin Error

[rnash679]

I made my first med error as a new grad; I flushed a peripheral IV with heparin flush. Didn't realize my error until shift change, 9 hours later. Patient was okay. Told my preceptor. I feel absolutely horrible and like I made a huge mistake and could have really hurt someone. How do I feel better about this? I keep stressing over the effects this could have had on my patient. 

[CalicoKitty, BSN, MSN, RN]

PICC lines used to have heparin in them to prevent them from clotting. Peripheral IVs also used to get flushed.. That's why a lot of people still refer to them as "hep-lock". I believe dialysis access lines still use them, but they put in a measured amount (marked on the line) so just to fill the line, not a real 'flush'.  Heparin flushes are often 3 ml syringes in yellow packaging. The dilution is different than the heparin used for SQ injection (which comes in vials and carpuject systems).

[Melissa Davis, DNP, RN]

Hi, my heart goes out to you because you are in fact a second victim of your error, as we all are. My research is focused on nursing medication errors and I can tell you this:

1. You were probably given the message in school that, if you are smart enough and care enough, you will not make errors.  WRONG. 

2. All humans make errors continuously-- I just made two typing errors while writing this post.  It is not reasonable to believe that, as nurses, we will suddenly get perfect.  

3. What really needs to happen is: nurses need to be taught how to spot the systems risks that make it easier to commit the all-too-human and inevitable error.  We can then alter systems to reduce the risk of errors. I bet that, if we talked about your incident, you would find that packaging is similar with the flushes, or you were in a hurry, or had a migraine, etc. -- all things that affect humans' ability to be perfect. We are not robots, a good thing,  but that also leaves us vulnerable to our errors. 

4. Use this as a learning experience-- it's not win or lose, it's win or learn.  That's all you can do at this point-- and forgive yourself.  You cannot be blamed for being human. 

Anyone who tells you they don't make errors is lying.  I have 40 years behind me and have made plenty of them. 

I'm here if you need more support.  It's OK. 

Melissa Davis DNP RN

 

[londonflo]

1 hour ago, Melissa Davis said:

Use this as a learning experience-- it's not win or lose, it's win or learn.  That's all you can do at this point-- and forgive yourself.  You cannot be blamed for being human. 

I love the "win or learn" phrase!