Incident Reports

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Specializes in ER; HBOT- lots others.

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

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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.

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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?

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Specializes in OB-GYN.

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

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Specializes in Case mgmt., rehab, (CRRN), LTC & psych.

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.

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Specializes in Cardiac Telemetry, ED.

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

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Specializes in Cardiac.

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

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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.....

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Specializes in Cardiac.

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

Still, it all sounds funny.

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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?

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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.

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Specializes in ER; HBOT- lots others.

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!

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