Hello. Just needing to vent and ask for some advice. I'm a new grad at a CVCU, I started working December 2023 so still a new grad. Recently, I had a patient on a nitro and amio drip who only has a PIV. He has been on the nitro and amio drip for 3 days and we have to change the nitro and amio drip site every 24hrs (since its not going through a central line).
Okay anyway, when I had him, his nitro and amio drip's PIV was nearing 24hrs, so I put in 2 new IVs on his arm... and when I got report the next day, the nurse told me she had to report me to management because one of the PIVs I inserted was facing towards the hand, not the heart.
Oh my god.. I feel so terrible. The PIV that was backwards was the amio drip and that is a vesicant. Things could have gone terrible. Thank goodness that it didn't. Thank goodness his vein did not burst. To make things worse, I forgot to tell the nurse to not re-use the other two PIVs in the other arm since the 24hrs for those PIVs have been already used. So, she ended up using one of then again for another 10hours after she removed my backwards PIV.
I feel so terrible. I learned in nursing school that all IVs need to face the heart, so when I did this PIV backwards, IDK why I did it! I have no idea. I was not paying attention? I don't know! Oh my god. I feel terrible. I'm currently waiting for management to talk to me. Has anyone made a mistake like this before? I cannot stop thinking about it. I feel so bad. IDEK who makes a mistake this stupid
TLDR: I inserted an IV backwards (facing towards the hand) and a vesicant drip was going through it for hours. The next nurse caught it and reported me to management
While yes, putting in an IV backwards can be bad, don't beat yourself up too much about it. I bet you'll never do that again, learn from it. Also, and this is only my opinion which in the grand scheme of things means very very little, stick up for yourself. Play off it. If someone says something about it in a public area about it use some light brevity and say something like "trust me, ill never make that error again" and people will forget and move on .
Thank you. The day shift nurse actually mentioned it to a couple of our co-workers and I kinda was just like "yeah I wasn't thinking... I don't know why I did that even though I learner in nursing school that IVs should face the heart. I definitely won't do it again.”
And we kinda just laughed it off after that, but I felt a little bad that she mentioned it to others. It's okay though. I'm just hoping everyone forgets about it haha. It's so embarrassing
Specializes in ER, Hospice, PEDS,Teaching, Rehab, Critical Care.
Hi Peace,
I just wanted to join in giving you love. Oh boy, have we all made mistakes?And here are some of mine in my first 2 years as an RN just to make you feel better:
accidentally weighed a pediatric patient in pounds instead of kilograms for a moderate sedation, and almost double medicated him, thankfully, the doctor (who, by the way, hated me already), found my mistake before we gave the kid the drugs.
Underdosed a cardene drip by ten times, thankfully, it was an underdose by ten times and not an overdose because my oncoming nurse found my mistake.
Had a really tough peds IV start and finally got labs, but I left the labs in the tube station for 3 hours, and of course they coagulated. Once again the oncoming nurse (who also, by the way, didn't like me, nurses eat their young right?) found my mistake, and unfortunately, the kiddo had to be poked a few more times just to get blood.
Got publicly shamed and kicked out of my very first trauma (GSW) because I almost blew up the rapid infuser from the pressure and clamping.
I could go on and on and on... Please try to be nice and gracious to yourself. Even if no one else does. It does get easier - you gain lots of muscle memory. You will become an expert, but every nurse, no matter experience, continues to make mistakes. So just try to remember to stay present, double check, use the resources available to prevent unnecessary errors as needed, and avoid practice drift. Hugs to you!!
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
Aesopian said:
I agree. That was an extremely rude and crude thing to do to a coworker. Did you both do walking rounds and check the lines before the hand off? That usually helps to catch things like this.
I disagree. I think it was a nice thing to do -- she had to report the infiltration. It was nice to give the coworker a head's up rather than letting management blindside her.
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
Peaceofnurse said:
I felt really bad about what happened. My co-workers (in nightshift) are all very nice and helpful. But sometimes day shift nurses, especially the older ones, can be a little mean. I don't know if mean is the right word but they can sometimes just say things without a filter or they tend to report things a lot more often. I hope that doesn't come off the wrong way but some older day shift nurses in my unit tend to just be a little irritable. I totally understand though because burnout is a real thing.
At my last job, management (our nurse manager) made rounds in the morning at 10am with her boss and her boss's boss. The patient was scrutinized for things like central line dressing integrity, date, time and initials on every dressing, every IV line, every IV bag or tube feeding bag, neatness of the room . . . just about everything. If you had forgotten to change a dressing, or forgotten to change your IV tubing (every 8 hours on some drips) or hadn't dated, timed or initialed it properly, a incident report had to be filled out immediately and turned in before the manager left the floor. Some of our patients had 12 drips, two or three central lines, arterial lines, surgical sites, etc. A LOT of incident reports were initiated on those management rounds. My point is, the day shift nurses may not have a lot of choice about when to "report" something.
One night I had a patient with a dozen drips, two arterial lines and two central lines and a few surgical site dressings. Because it was my birthday after midnight, when I made up all my date/time stickers before I even started changing the lines, I dated everything with my birth date (month, date and year of my birth in the last century) rather than the actual date. The month and day were right, but the year was WAY off. I got written up for that. My manager said, "I know you changed all your lines and dressings, and everything looked pristine. But my boss was horrified at the date, so I had to write it up."
Everyone gave great advice. I am an ICU nurse at a Veterans Hospital. Management will give you refresher training in IV and IV high risk medications and what to do in case of vesicant. I tell all of my new nurses no matter how busy you get never ever rush, because that's when mistakes happen. Take your time and think things through. And as all the other nurses said use that as a learning lesson.
It sounds like you're dealing with a toxic environment. As an experienced nurse, I would've just made sure to chart my first assessment thoroughly—not to blame anyone, just to cover myself. Your coworker failed also by not doing so and still using the IVs, not asking when and for how long they had been used for. If the patient wasn't harmed and it was more of a near miss, I would've brought it up during report, educate you, and maybe even gone to the room for bedside report to ensure everything was correct. Don't feel bad about it; we're all human. Every nurse has made mistakes at some point—anyone who says they haven't is probably not being honest. Don't let this weigh on you too much.
Peaceofnurse
4 Posts
Thank you. The day shift nurse actually mentioned it to a couple of our co-workers and I kinda was just like "yeah I wasn't thinking... I don't know why I did that even though I learner in nursing school that IVs should face the heart. I definitely won't do it again.”
And we kinda just laughed it off after that, but I felt a little bad that she mentioned it to others. It's okay though. I'm just hoping everyone forgets about it haha. It's so embarrassing