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Discussion

Made a dangerous mistake

Had a patient with a mag level of 1.7. and doc ordered 2 grams of mag to run over two hoursX2doses. I programed the pump perfectly, set it at 50ml/hr for a 100ml bag. Had another nurse double check the setting. I hit the run button and after 2 minutes I noticed that almost all the mag had infused. :no::o I made the mistake of hooking the piggy back tubing below the pump. :arghh:.

I know this is basic nursing stuff and I don't know what the heck I was thinking. Obviously I wasn't thinking at all.

Thankfully the patient was okay, after all of this. The Doc was notified ofcourse and didn't act too concerned.

This scared me so much. I felt like such a incompetent and unsafe nurse.

I'm still hunted by this..... I feel terrible. I've been a nurse for 4 years, and I know better !!!

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    • Featured Replies

    You can "push" magnesium sulfate IV in certain situations. We used to "push" it all the time for seizures, torsades, and other stuff. Pushing it fast in this manner is usually OK unless the patient is in a heart block or just had an MI. For simply hypomagnesium, we give it over a couple of hours, just as you meant to do.

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    After reading several posts today...I just keep thinking...what kinda pumps are these...NOT the nurses. These posts sound more like mechanical error not human error! :***:

    When you set a pump it should run correctly no matter which way the tubing etc is as long as the tubing's attached correctly to the right port (primary or secondary). My facility has plum pumps. I've not ever heard of problems like these.

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    After reading several posts today...I just keep thinking...what kinda pumps are these...NOT the nurses. These posts sound more like mechanical error not human error! :***:

    When you set a pump it should run correctly no matter which way the tubing etc is as long as the tubing's attached correctly to the right port (primary or secondary). My facility has plum pumps. I've not ever heard of problems like these.

    It's because it wasn't going through the pump it was free flowing.

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    • Author

    The previous poster is correct. Secondary tubing should always be set above the pump so it doesn't go in as a bolus.....My stupid mistake. Cannot blame the pump at all.

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    Our secondary tubing is way too short to reach the only port below the pump- which is way down the tubing. Having a hard time picturing this but I'm glad it was okay!

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    Too many tubes, ports, programming....WAY too many options for a busy nurse!

    We all make mistakes, no patient harm came, and perhaps patient is at a theraputic level now.

    You are an exerienced nurse and know what you are doing. Don't let this one mistake mess with your head!!

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    There are times where you actually push magnesium. It isn't like pushing potassium (which would have been much worse)- you learned from it. Patient is ok.

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    Our secondary tubing is way too short to reach the only port below the pump- which is way down the tubing. Having a hard time picturing this but I'm glad it was okay!

    Same. Our secondary tubing is so short that I have a hard time visualizing what happened.

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    • Author

    I appreciate the encouragement. I thank God the patient was okay .

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    **** happens!! of course we don't want to be blase about mistakes, but we have all had our 'd'oh' moments. I'm sure you will never make that mistake again!! Don't worry about it and get back to work saving lives;)

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