Made first big mistake at work :(

[Apple4159]

Hi. Been working in a level 4 nicu for one year now. I was a new grad when I started. Everything has been going pretty well so far.

Last night I took a difficult baby, 23w, vented. I gave her blood through a PIV the day nurse had put in.

Blood runs, everything is fine... I changed the t-piece on the IV and I forgot to flush it!! I've never given blood before and never changed a t-piece... of purse on day shift the IV clotted off, and it was escalated, as the air in the tubing could have harmed the patient.

I also didn't document stopping the blood and saline locking it.

I feel horrible. The baby was not hurt and didn't need IV access afterwards. My manager saw me in the hallway and grabbed me and talked to me about it briefly.

It's all I can think about. I'm glad the baby wasn't hurt (I had her again the following night) but I'm angry at myself for being careless.

I have definitely learned for next time.

[IVRUS, BSN, RN]

Apple,

Sometimes lines clot off even though they are flushed. Should you have flushed the line s/p transfusion... Yes, but worse case scenerio, the neonate required another venipuncture to gain successful access. I am unfamilar with the T piece/purse you are referring too... Is this the extension set?

[Baby Wrangler]

I think Apple is talking about the T-piece that you would attach to the IV catheter of the PIV. We generally change the T-piece of a PIV (and prime it with saline) after giving a blood transfusion because it's hard to flush all the remaining blood out of the old T-piece.

Apple, don't beat yourself up about it. I'm sure that you will remember this from now on. It sounds like you had a busy shift with the 23 weeker and that's why you forgot to prime the T-piece. At least it wasn't the whole tubing set or whatever and the baby wasn't hurt. I wouldn't say that the air in a T-piece is negligible because it isn't but it's also not a huge amount. There isn't a single NICU nurse that hasn't done something that we've felt bad about and on the list of terrible things yours isn't even close to the top. Just take it as something that you'll never forget to do again.

[adventure_rn, MSN, NP]

Awww, that sucks. (((many hugs)))

I know it feels terrible to make a mistake, especially because our kiddos are so tiny, fragile and vulnerable. I know it's cliche, but everybody in every profession makes mistakes. You're remorseful, you learned from your mistake, and now you won't make it again. You weren't being careless or negligent; you were human. You're ok and baby is ok; try to cut yourself some slack.