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Incident Reports

Posted

Specializes in Ortho; Gyn; Urology; HBOT; Emergent. Has 8 years experience.

so i go to work the other day and get report like normal. something in report seems wrong... pt getting 2nd unit of blood and has her mivf d5.9ns w/ 20k piggybacked with it running at tko. first of all, this sounds wrong. so then i totally forget to even ask the nurse about it. i go in her room first and see her, check out her pumps and all these lines, sure enuf he has this running as stated. totally not in my head! so, the blood just happened to get done when i got in there, so got rid of that, but then i changed the tubing and all that, flushed her and started her mivf back up. talked to my charge, to confirm i am not crzy. i am still only out a yr from school, but not dumb, and this other nurse has been one lot longer than me, but i had to do an incident report. i felt like a tattle-tale. omg! i didnt have to put in his name or anything like that, but i still was just irked that he did this. he has been doing things like this a lot lately, and its like he would rather do personal things rather than make things correct.

i am happy and grateful nothing happened w/ the pt, but still. how do i ever say something to this nurse? i am totally usually the one to speak up, but this is very very touchy.

ty in advance!

-h-rn

Don't say anything to the nurse. You don't have to. That is the supervisor's job. If he asks you about it, just tell him what happened, but you don't owe him any apologies. He is the one who made a mistake, not you.

Virgo_RN, BSN, RN

Specializes in Cardiac Telemetry, ED.

Wait...if the MIVF were piggybacked, then the blood would not have been running, and the blood would not have finished at all. You would have walked in to find a full bag of blood hanging....am I misunderstanding what you mean?

Cassaundra

Specializes in OB-GYN. Has 3 years experience.

Interesting. Blood's not supposed to run with anything other than NS right?

TheCommuter, BSN, RN

Specializes in Case mgmt., rehab, (CRRN), LTC & psych. Has 15 years experience.

Let the supervisor do his/her job by approaching your coworker regarding his mistake.

As a floor nurse, you already have enough to do. It is certainly not a part of your job description to inform this guy on why the incident report was prepared.

Just continue to practice safely and prudently, and always cover your behind.

Virgo_RN, BSN, RN

Specializes in Cardiac Telemetry, ED.

Another thought. Blood tubing doesn't have a port for piggybacking, so how could the fluids be piggybacked?

cardiacRN2006, ADN, RN

Specializes in Cardiac.

Because that nurse also must have not used blood tubing is my guess....

Virgo_RN, BSN, RN

Specializes in Cardiac Telemetry, ED.

Because that nurse also must have not used blood tubing is my guess....

But still the blood would not be running if the fluids were piggybacked.....

cardiacRN2006, ADN, RN

Specializes in Cardiac.

Maybe they did use blood tubing, and instead of the NS it was the MIV.

Still, it all sounds funny.

Virgo_RN, BSN, RN

Specializes in Cardiac Telemetry, ED.

That makes more sense. It's not really "piggybacking", though is it? Still, it seems it would be tough to do, since those liter bags are so long and the blood bags are so short. The question is, does this have potential to harm the patient? Does it compromise patient safety in any way?

flightnurse2b, LPN

Specializes in EMS, ER, GI, PCU/Telemetry.

did this nurse put D5NS with 20mEq of K on the saline port of the blood tubing set? did he run the blood on normal IV tubing and piggyback the maintenence IVF.... bc like the other posters have said, if the IVF was piggybacked and the blood was primary, it would not have ran through the pump... or did he use the blood as a piggyback (since you said it ran in completely) and left the IVF as a primary?

i'm confused.

anyways, my boss makes us write up incident reports on each other too, which i think sucks and is unfair. if there is a nurse who makes a dangerous mistake like that, they need to be counseled by their superior. i had to put in a med error the other day on a nurse who worked the day before me and signed off orders for a bowel prep that was sitting in the patient's drawer but not given for 24 hours, and the pt had, of course an incomplete exam (and he was already gone from the room to the radiology unit when i got report on him). i felt bad, but it ended up going to her anonymously.... the doc was really po'ed and i really feel like my boss should have dealt with it.

NewRN2008, ASN, RN

Specializes in Ortho; Gyn; Urology; HBOT; Emergent. Has 8 years experience.

Our blood tubing does have extra ports like regular tubing. not like OR blood tubing like you might be thinking. i do know what you mean though. because that would make sense. he had the MIVF thru another channel running at tko, pb'ed thru the blood that was running thru another channel. So both were running just fine and dandy.

And correct cass, NS and blood are ALL that is supposed to be together NOTHING else.

I did tell my charge, and i think it is being dropped at that. thats why it bugs me. I am not going to approach him i guess. but it really bugs the heck outta me, cuz this is one thing of several that he has been doing lately that has been either wrong, not done, not addressed ect... WHATEVER! right?

Thanks for letting me vent!! thanks for all the replies as well!

-H-RN

HAPPY MEMORIAL DAY WKEND!

Where I work, specific names involved do not go on incident reports and copies do not get sent to the nurse involved. I can honestly say that on my unit, we don't maliciously fill out incident reports to spite each other. They get filled out to bring to light and track errors that could potentially happen again for whatever reason. Unfortunately, I know this is not the case everywhere. I've filled them out on myself before. If we do fill them out on something that happened on another shift, we usually inform the nurse who was involved by email or in person so #1) they are aware that they made the error and #2) they aren't surprised if the manager does ask them about it. Maybe you could email him to let him know that the error was found and that your charge nurse made you fill out the incident report.

locolorenzo22, BSN, RN

Specializes in Ortho, Neuro, Detox, Tele.

Nothing get's piggybacked with blood....you prime the line with NS, then run the blood, when blood is done, go ahead and run NS through the rest....regarding incident reports, just the facts and then finish the rest. we have been doing chart checks at shift change, and oftenI'm the only one willing to do em. I found a order on a chart, written at 0730, at 1900....to stop a drug, start another, so I had to fill one out.

Don't like doing it, but pt safety comes first.

Virgo_RN, BSN, RN

Specializes in Cardiac Telemetry, ED.

Our blood tubing does have extra ports like regular tubing. not like OR blood tubing like you might be thinking. i do know what you mean though. because that would make sense. he had the MIVF thru another channel running at tko, pb'ed thru the blood that was running thru another channel. So both were running just fine and dandy.

Ah, I see. I call it "Y-siting" when two different infusions are on two different pumps, and one is connected to a port distal to the pump, and thus both can run simultaneously. I was taught that piggybacking is when a second infusion is connected to a port prior to the pump and is run in using the same pump, with the "piggyback" setting. When an infusion is piggybacked, the primary infusion stops while the secondary infusion runs.

At any rate, you are correct that the way the other nurse set up the blood infusion was incorrect. Hopefully the IR will be used as a training tool and not a punitive device.

I definitely think you need to pick your battles with the whole incident report issue. I come across things almost every day I could 'write up' if I wanted to. . . missed/forgotten medications, unbathed patients, writing the blood glucose from 2am as the 6am fingerstick....

But I pick my battles, I save writeups for errors that truly harm/could have harmed the patient. Example: the DKA 20-year old in a coma who came up from the ER on an incorrectly programmed insulin gtt. It said 12 units an hour, she was actually getting less than one. That, I wrote up.

I would never have written up something as minimal as piggybacking D5 at KVO into blood tubing. Against policy? Sure. Could it have harmed the patient? No. That's where you go to the nurse and say, "Hey, you probably didn't realize, but...."

Call me ballsy but after a few years you learn when to use professional judgement with your coworkers.

but it really bugs the heck outta me, cuz this is one thing of several that he has been doing lately that has been either wrong, not done, not addressed ect... WHATEVER! right?

Thanks for letting me vent!! thanks for all the replies as well!

-H-RN

HAPPY MEMORIAL DAY WKEND!

You don't know that things you've observed are not being addressed with him and you won't know what if any action is taken regarding this. You're not entitled to information on disciplinary issues involving other people unless they choose to share it with you.

NewRN2008, ASN, RN

Specializes in Ortho; Gyn; Urology; HBOT; Emergent. Has 8 years experience.

Kids,

I do not mean that i want to know that he 'got in trouble' for what he did. i just dont think that he will even be made aware that something was done wrong. that was my point. i dont care about anything beyond that, just that he would be made aware.

i do understand what you mean though and totally know its none my bus! lol

-H-RN

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