How Could This Happen?

Pediatric Critical Care Columnist · Jul 13, 2009

It's not all that uncommon a problem, believe me. Whenever the connections for different types of tubing are physically connectable to IV tubing, this sort of error can occur. Patients have had BP cables connected to IV ports in error, causing air embolus and death. Others have had tube feeds connected to the port on the pilot balloon for their endotracheal tube's cuff, which subsequently ruptures, flooding the lungs with formula and causing death. Medications intended for feeding tube administration, when drawn up into syringes with Luer lock connections, have been given via central line, with predictable results. When infants and children are having tube feeds initiated in the ICU, there may be a shortage of feeding pumps and since the hourly volume of the feeds will be small, some practitioners will choose to use a syringe pump to deliver the feed. The syringe has a Luer lock connection, and it's entirely possible to infuse feeds through IV tubing (rather than specifically designed feeding tubing that has a Luer device and one end and a larger diameter, friction fit connector at the other), which increases the risk of misconnections. Safety engineering to decrease the likelihood of misconnections is a continual process, but the best systems can still be defeated by the human factor. Some of the documented incidents were the result of non-licensed personnel, such as housekeeping, accidentally dislodging the connection or finding a connector detached then reconnecting to the wrong port. When an overworked or perhaps undertrained health care provider doesn't take the time to follow the tubing to its point of entry to the patient, or chooses the incorrect tubing for the task adverse events are often the result.

Jolie, BSN · Jul 13, 2009

Another factor in these glaring, preventable errors is lack of historical perspective.

It seems that certain errors are repeated every so often. I started in the NICU in the 1980's. When I was a newbie, there were some incidents involving heparin mix-ups attributed (in part) to similar appearing vials of different concentrations. This same situation was repeated at Riley Children's Hospital in Indiana and with Dennis Quaid's twins and other babies in California. It is my opinion that the lack of incentive for experienced nurses to remain at the bedside contributes to the repetition of these grave errors, because those who are "old enough" to remember the factors which contributed to the errors have largely left the drudgery of bedside care for greener pastures, and newer nurses don't unerstand the basis for certain safety precautions, making them seem unneessary.

Another example involves the electrocution of infants inadvertently "plugged into" detachable power cords mistaken for portable monitor cables. Back in the mid-80's, it was common to use durable EKG leads which plugged into the monitor cable with a "male" end prong. One day, biomed came into our NICU and removed all of those leads, explaining that they had been linked to the death of an infant (I don't know where) whose caregiver accidentally plugged the male end of the EKG leads into a power cord (which detached from the back of the portable monitor) instead of the monitor cable. After that happened, most units switched to monitor leads with "female" ends, making it impossible to plug them into power cords. It was understood that detachable power cord + "male" end EKG leads = potential for electrocution. But apparently some units continued to use these products. Fast forward about 10 years. Another story involving the death of an infant under the same circumstances. I suspect that there were few nurses working in that unit with enough experience to remember the previous tragedy, and/or administrators who failed to appreciate the safety risk of using older equipment that had not been modified to prevent this error (if the power cord of the monitor had been permanently attached, it may have prevented the error.)

We need experienced caregivers to offer a historical perspective on safety or we are doomed to repeat these errors over and over again.

Pediatric Critical Care Columnist · Jul 13, 2009

Excellent points, Jolie. This lack of experience seems to be compounded by the gradual decrease in clinical exposure that students receive while learning the art of nursing. Concepts, theories and algorithms are all well and good but they don't replace the hands-on. This limited clinical exposure also results in decreased opportunities to develop time management, organization and assessment skills such that the new nurse in acute care is easily overwhelmed. Add to that the increase in acuity seen in hospitalized patients and the staffing shortfalls many units experience, the unfortunate habit of failing to provide a consistent preceptor for new staff members who are then pushed out of the nest unprepared and you've got a recipe for disaster.

Guest233447 · Jul 13, 2009

Thank you all for your insight into this.

As a future "new" nurse, it seems the biggest concern experienced is the lack of time that nurses have combined with a patient load that is overwhelming.

I don't know how I'll learn to cope with these things, but I'm happy to have already found Allnurses and the voices of experience that are here. The insight provided here has already proved invaluable to me.

A girlfriend who works in healthcare (admin side rather than "hands-on") says she would never be interested in nursing. Between the overload experienced in patient care, she says that the nurses at the local hospital here are extremely negative and critical of each other. The "back-biting" is incredible, and she worries about me. She recommends I work outside a hospital.

Since I have your attention, how do you deal with these issues - high patient load and negative work environment?

Fiona59 · Jul 13, 2009

But you have to bear in mind that a "negative work environment" is different to each individual.

The unit I work on is great, my co-workers are some of the nicest people I've ever met. Yet, my within my hospital my unit is dreaded. The casuals hate coming because basically we are the dumping ground with numerous isolation patients, icu transfers and basically crazy/insane family members.

High patient load? Hmm, on days it's 3-4 patients, evenings are 5, and nights average 7. Hardly the backbreaking ratios described by our US posters. LTC is a different kettle of fish. You treat each patient as an individual and remember that hospitals are open 24/7 and there is a shift after yours.

If I had to do it over, I wouldn't be a nurse. I'd be a health records technician/coder in a nice cubicle with zero family contact and exposure to bodily fluids. PN and Coders are both two year college programs and yet the coders are paid more than a LPN and they get all their breaks.

Guest233447 · Jul 14, 2009

She's a fairly hard-nosed type - not given to expecting cupcakes and hugs in a work environment. She's worked at Capital Health for over 10 years before moving to the Peace Country HR and she says she has NEVER seen the like of the staff (nurses, dr's, techs) having such negative morale anywhere else. I like to think that I'll be able to manage to rise above, but I HOPE that it isn't as bad as she's saying.

I've seen you mention Coding - even mentioned that to her. She said, "As long as you like to sit in the basement in a cubicle staring at a screen all day." Hearing that reminded me that, all things considered, I've chosen nursing to avoid that scenario. I love people, I love helping people, and I cannot stand sitting in a cubicle.

All I can hope is that I will make a good nurse, make a difference in people's lives each day even if it's just a smile, and manage to be a somewhat cheerful spot in a Health Region that seems to have the doldrums.

And in 2 years maybe this horrible, unecessary restructuring will be over and things will be happier all around. :)

Fiona59 · Jul 14, 2009

The coders in my hospital are on the main floor in an area windows.

Let's just put it this way, three times this month I've had to throw away a uniform at work and beg for a set of hospital issued scrubs because I don't want to take stuff home that are covered in the bodily fluids that will best be left to your imagination. I don't want that sh*t in my washer.

I have a feeling that in two years time things will still be the same. In this province people keep re-electing the same idiots and then turn around and b*tch about service cuts.

Guest233447 · Jul 14, 2009

Aw. You sound discouraged. Think of it this way: you get the opportunity every day to make a little, positive difference in the lives of both patients and coworkers. Sitting there coding wouldn't be nearly so adventurous, or interesting. You'd be bored, and looking for higher meaning in what you do.

I have a washer that has "sterilize" setting. Haven't used it yet, but imagine I will.

Maybe I shouldn't bother buying "nice" scrubs though? LOL

allnurses Guide · Jul 14, 2009

Curious Student-- I think it's great that you are already observing and thinking about what kind of nurse you want to be and reading accounts in the press about nurses and nursing. I never did that, and I had a a h*ll of a time reconciling what I saw in clinical with my (apparently) naive view of the profession. There really is a lot of stuff to process emotionally in addition to all the studying of A and P, Pharmacology,etc etc

This forum is a great place to air out and discuss issues that are troubling and I wish I had something like this when I was starting. You will hear a lot of negative things said, and it may seem like that's the dominating emotion, but it's kind of like the news-- people naturally focus on things when they aren't right rather than when they are!

Everytime I read about a horrible error that ends in a patient's death, I try to brand it in my mind. I never want to let down my guard. Never, never never. Also, and this is the saddest for me when a good nurse makes a catastrophic mistake. We all wonder, how could this happen??? It does. A perfect storm of bad circumstances like the posters above have talked about.

Anyway, hope you'll hang around the Student Nurse Forums as you progress through nsg school, good luck to you!!:wink2: