I'm a new grad RN who has been on my own for about 2 months now. I had a 6 week orientation prior to being on my own. I'm on an incredibly busy med-tele floor. And today I made my first error--a HUGE error at that. My patient was to receive a blood transfusion. He was a very sick patient who had 4 channels running with antibiotics, fluids, electrolytes, and blood. I accidentally let the blood transfusion run too long. I can't believe I let this happen. When I looked at the order I thought it was for 4 hours. However, the order was actually for 3 HOURS. And then, around 6:30 right before shift change I was told I had to transfer the patient to a different floor and my charge nurse was very adamant that it needed to be done ASAP. Around that same time I was trying to pass medications and another nurse called to ask if I can switch shifts with her and when I told her it wasn't a good time she got the charge nurse on the phone who kept trying to talk to me about scheduling and me switching shifts with the other nurse. I told her I hadn't even had a chance to sit down all day and chart, let alone look at what my schedule is, and that I would let her know later, but she just kept trying to fix up my schedule. At the same time I had a discharge who had been waiting all day to leave, a patient who needed to be cleaned up, meds to pass, and had to transfer this patient upstairs. I called report and transferred the patient and never turned off the blood. I didn't even know what I had done until the nurse from the other floor called me an hour later and said I had made a huge mistake. Not only was I supposed to have turned off the blood at 6:30, it had run up to 7:50. It ran for 4 HOURS AND 20 MINUTES. I notified my charge nurse right away and called the doctor, and we had to write an incident report. I can't believe I made such a big mistake. I'm crying and so angry at myself for missing something so big. We are so busy on our floor with so many things going on at once, it feels like I'm being pulled in so many directions and I can't keep track of everything. However, there is no excuse. This was MY fault and no one else's. I should have been paying more attention, I shouldn't have let this happen. I don't know what to do. I don't wanna go back to work, I don't want to show my face again.
I would not have made a fuss over this if I were the receiving nurse. Sure, it was an error, because blood went past 4 hours, but in the grand scheme of things it's very small.
You said you start blood at 50mL/hr, and may have forgotten to bump the rate. I have almost done this myself early on. What I do now is start at 75mL/HR, stay for 15 minutes to observe the patient for any transfusion reaction, then bump the rate to 125/HR before I leave the room.
Your charge nurse was a contributing factor to this error, because she and the other nurse caused you to be distracted. Instead of backing off when you said it was a bad time, they pushed on. A good charge would have stopped and asked if you needed help. Additionally, as a charge nurse I will check on patients who are receiving blood of the nurse is someone new. That would have been nice in your case because someone may have caught the low rate.
Next time someone tries to get your attention like that (for something not important) when you are super busy, tell them a firm NO.
You owned up to your error, now make a plan to prevent it in the future )mindful of rates, telling distractions no), and forgive yourself.
I don't think that's a huge mistake, either. Be kinder to yourself! The patient got the blood as ordered. Sure, it's supposed to run in quicker than you ran it in, but he got what he needed. It was just petty on the part of the other nurse to even say anything.
I got dinged once because I'd had a patient at night who got transferred the next day, and the floor nurse who received him saw the tubing didn't have labels on it. Both myself and the daytime nurse who transferred him up got emails about it. It's like - really? I know labeling the tubing is important, but I was really busy that night (more patients than I should have had per standard ratio, with multiple admits) and it just slipped my mind... and by the way, the patient got admitted on my shift that night - so deductive reasoning could have told you that the oldest the tubing could have been was about 18 hours old. It definitely wasn't over the four day mark on a new admit.
Some people just live to find mistakes that other people have made and make a big deal over it. I personally would have just taken your blood down and not said anything if it was me.
Specializes in Medsurg/ICU, Mental Health, Home Health.
1) You are changing that username NOW.
2) This isn't a med error.
3) The reason why blood is supposed to be run in in less than four hours is because of potential bacterial contamination (and hemolysis maybe...maybe?) However, this time limit is one of those "this is the way we do it" things more than evidence based practice. Unfortunately, the NIH stated in 2011 that studies require to change this arbitrary limit would be exhaustive and costly.
4) Check your facility policy on transfusions, then please report your findings back to us. That way we can help you better determine appropriate rates for transfusions. I worked in acute care for nine years and checked my policy nearly every time I transfused someone with ANY blood product. Unless you're transfusing all of the time, those rules can be sticky and easy to forget.
5) Running a bit overtime is preferable to flash pulmonary edema from pouring the blood in too quickly.
6) Incident reports are NO BIG DEAL. They are used to keep an internal record of things that occur outside of protocol and are also used for learning purposes. Do you know how many incident reports I wrote up on myself? Lots! Not because I'm a bad nurse but because I'm an honest one. I'd rather have that IV infiltrate documented than have it bite me later (most of my incident reports were IV infiltrates).
7) Take a deep breath. Take a nice hot shower. Drink a cup of hot tea. Keep fighting the good fight. :)
Specializes in Oncology, Rehab, Public Health, Med Surg.
Echoing others---change the user name. Maybe to - learning all the time?Honest, this is just a learning experience.
As a new grad, I punctured one of those blood bags once. Yep, blood evertywhere. Me, all over my white uniform, patient, floor, bed---everywhere!! Try and live that one down, lol Theres a thread here about rookie mistakes we've all made-- hilarious. Find it- read it--I promise you'll feel beter
And the nurse that told you it was a HUGE mistake?
Pffffft- just trying to make herself seem smarter. ( really smart people don't put people down for mistakes)
Specializes in MCH,NICU,NNsy,Educ,Village Nursing.
I'm with other posters. Change the name. You are NOT stupid, and don't let anyone tell you otherwise and don't tell yourself that. Hang in there. You'll learn from this.
The first time I hung blood I ran BOTH units too slow, timed out on both, and the patient only got partial units. I thought I was the worst nurse who ever lived, I would never get this, shouldn't be trusted with anything more significant than Tylenol... And I got over it.
I'm not saying to brush off every single oversight... I am saying to take them as learning experiences, take a deep breath, and tell yourself you will do it differently next time. I talked to a trusted friend, and told her, "next time I will set an alarm on my phone to speed up the blood. I'll check up on the NAs to make sure they are ACTUALLY getting on time vitals." I came up with a plan to do it a little better next time.
I make many, many mistakes every single day. I get talked to about them sometimes. Every time that happens, I take a deep breath, and try to verbalize a plan for not letting "that" (whatever it is) happen again. I accept responsibility, and ask for feedback on what I can do differently. Not just to placate The Evil Management... But also to make myself feel like I have more control over my shift and my practice. (BTW, sometimes I cry while I'm asking for feedback. I'm working on that. It's hard. But it's ok, it's who I am.)
Something like this will probably happen again. It's inevitable that you will drop the ball. That's ok. What matters is if you learned something from it, took accountability and thought about how you would handle the situation better (NOT PERFECTLY!) next time.
This is a process. It feels like you are the only one making mistakes. You are absolutely not.
The hardest thing for me is asking for help. Ask for help. A new nurse is going to come to you, with tears in her eyes, much sooner than you think, and whisper, "OMG, I made a horrible mistake. I don't know what to do..." She is going to look up to you, see you as a more experienced nurse, and trust you to help her make it right. Be that nurse to her, the one that you needed today. That's how this turns into a wonderful, positive experience (that didn't really hurt anyone.)
You are not stupid. You are on the path to being a compassionate mentor.
I thought you were going to say you forgot to DC a heparin drip or something. THAT's huge.
This, not so much. Unless your patient died from an unmonitored transfusion reaction. THAT's huge.
Just letting the blood go for a few minutes longer than it should... eh. On a scale of zero to ten of patient harm, this is maybe a 3. Probably a 2. OK, a 1 1/2.
Here's what I got from your post that you could have changed:
A) You should learn to put your foot down. If you don't have time to talk, you don't have time to talk. It's OK to hang up on people when they are being ridiculous.
B) You should not have been transferring the patient if you were that busy. Most hospitals have transport that can transfer the patient, unless they are on the monitor with no orders for nurseless transport. At the least, your unsupportive charge should have taken the patient for you.
C) You should have asked for help long before you got that far behind.
D) Learn to say "no." "No, I can't talk now." "No, I can't transfer that patient." "No, I can't interrupt my med pass to talk to you." "No, I can't help the CNA clean this patient up, I have to pass meds." You are the licensee, you do the licensed tasks. The CNA is the unlicensed assistive personnel, they do the unlicensed tasks. If you could do it all yourself, hospitals wouldn't pay for CNAs.
E) You cannot do everything yourself. I have a nurse friend who is a control freak and tries to do it all. She's been disciplined many times for overtime, almost to the point where she's lost her job. Don't be like her. Ask your fellow nurses for help. If they say no, call the charge nurse. If the charge nurse can't help, call your resource nurse. If you don't have resource nurses or they aren't available, call the house supervisor.
I've always said there's no need to drown when you are surrounded by lifesavers. If you don't grab one, that's your own fault.
You will be OK, but you need to stand up for yourself. Chalk it up as a learning moment, and don't EVER let yourself get so busy that you have that problem again. If you are not able to handle the patient load yet, let your manager know. If you have a good manager, they will let you take a smaller assignment until you are more capable, or at least give you pointers on how to manage. If you have a bad manager, don't say anything. They will see it as a sign of weakness and dive right in to prey on you. Find a nurse mentor. There's almost always that one person on the unit who mothers the new grads.
New grads need to be supported for the first year. That's just the way it is. It takes you that long to get used to the critical thinking, the culture of the hospital, and the ins and outs of your specialty. If you are not getting that support, it is not your fault. Hopefully you can talk to your coworkers and management and get things straightened out for yourself.
BTW, you're only stupid if you make a mistake and don't learn from it. I am not happy with your choice of username. Beating yourself up doesn't help anybody.
Now, for blood administration: (Those of you who know what you're doing can skip this part, LOL!)
Most hospital policies are the same. Find yours and print it out so you are familiar with it next time. You fill out a form or put in an e-request with all of the relevant info (patient name/DOB/MR#, blood bank #, blood product needed, ordering physician, location of patient).
Once you get the blood, you have thirty minutes to decide that it is OK to administer or you need to send it back to blood bank. You get your second nurse to verify the unit. Once the bag is spiked, you usually have four hours before the blood expires. Get a set of vitals pre-transfusion. When you have your tubing all set up and connected to the patient, start running your blood. I usually run it at 999 cc/hr until just before it actually goes in the patient. Then I set the secondary for 75 cc/hr for 15 minutes. (Only on pumps that don't have a separate secondary port.) I set the primary for whatever rate is appropriate according the patient age/condition and the IV size. That way I don't have to remember to change it. Your start time is the minute that the blood hits the patient. It's stupid to waste your 15 minutes watching NS going in, so don't start your time when you hit the START button. Wait until the blood is actually going in.
The smaller the gauge, the slower you go. I never run it more than 125 in a #22 to prevent hemolysis reactions. I also never run it over 150 if the patient is over 65 or has CHF or PNA. ARDS sucks.
Stay with the patient for the first 15 minutes to check for s/sx of allergic reactions. I usually take a mobile computer and use that time to chart. Once the 15 minutes is up, get another set of vitals. If the BP goes up or down by 30 points, the HR changes 20 beats from baseline, or the temp goes up or down 3 degrees, you've got a reaction and you need to stop the blood, pronto. Let the doc know, keep NS running at KVO (or your policy's rate) to keep the IV open so you can administer steroids/benadryl/whatever, and send the whole shebang of tubing and blood to blood bank for testing.
If there's no reaction, check on them an hour from the time the blood started and get another set of vitals. Rinse, repeat, until all the blood is gone.
I'm very confused. Was the patient not supposed to get the whole unit? If you wanted the whole unit anyway, and you weren't trying to do 1 hour units or something for severe GI bleeding, this is a minute mistake at worst. The other nurse was probably just making an issue over it because now she had to take the unit down. Our units of blood are not exactly uniform volumes, so we can't give them over an exact time frame. I'm surprised the doctor didn't laugh when you called to report this error.
I suspect you need to learn to delegate a bit and take a firm but respectful tone of voice to survive a unit like this. I'm not sure why your patient was being transferred and why the charge nurse wanted it done ASAP. Was it increased acuity to a higher level of care? Then get it done- less of your plate. Something else? It can wait a bit and your charge nurse can do it herself if she feels it's some important. I'm not sure if your charge nurse takes their own full assignment or how much is on their own plate. Now- scheduling issues? Not even on my mind- that's where your firm but respectful tone comes in. Cleaning a patient up? Do you have aids?
Thank you so much for your reply. He was supposed to get the whole unit but it was supposed to have been over 3 hours. He didn't have a GI bleed or anything. His Hgb was 7.2. But when the nurse called me and told me I made a huge mistake and that she was going to get in trouble because of me, I just figured this was the biggest mistake I could have ever made, especially because it had to do with blood.
The patient was transferred to a floor where he could get chemo. If we don't transfer our patients promptly the house supervisor usually comes down and gets angry with us because we're holding up 2 rooms and our hospital is so full that we have people in the hallways of the ER.
I agree I will need to be more assertive. It's just a little difficult for me sometimes because I have a very straight forward, blunt charge nurse who is much much older than me and I don't want to seem disrespectful in any way.
As for the cleaning up, our CNA's have 16 patients and so it's very difficult to get ahold of someone to help because they're usually running around just like I am. I do wish we had some more help.
Thank you so much for responding. I'm going to practice being assertive and I'll really try to hang in there and just learn from everything and not let it bring me down.
3) The reason why blood is supposed to be run in in less than four hours is because of potential bacterial contamination (and hemolysis maybe...maybe?) However, this time limit is one of those "this is the way we do it" things more than evidence based practice. Unfortunately, the NIH stated in 2011 that studies require to change this arbitrary limit would be exhaustive and costly.
4) Check your facility policy on transfusions, then please report your findings back to us. That way we can help you better determine appropriate rates for transfusions. I worked in acute care for nine years and checked my policy nearly every time I transfused someone with ANY blood product. Unless you're transfusing all of the time, those rules can be sticky and easy to forget.
5) Running a bit overtime is preferable to flash pulmonary edema from pouring the blood in too quickly.
6) Incident reports are NO BIG DEAL. They are used to keep an internal record of things that occur outside of protocol and are also used for learning purposes. Do you know how many incident reports I wrote up on myself? Lots! Not because I'm a bad nurse but because I'm an honest one. I'd rather have that IV infiltrate documented than have it bite me later (most of my incident reports were IV infiltrates).
7) Take a deep breath. Take a nice hot shower. Drink a cup of hot tea. Keep fighting the good fight. :)
Thank you so much for all of the information and for taking the time to respond to my post. Now I understand why there's a time limit on blood transfusions. Also, I was so worried about the incident report because I thought this was like a write up for me. I feel like I can finally breathe now.
Nurse SMS, MSN, RN
6,843 Posts
Oh. And I want you to change that screen name right. now.
You don't get to call yourself that. Not over this. Not here.