med mistake/question

Pediatric Critical Care Columnist · Nov 12, 2007

I think it's a tempest in a teapot! If the IV solution was compatible, and was running at any kind of a rate, the Dilaudid was already circulating in the patient before you could even think about flushing. The only thing would be the small amount of drug sitting in the port (~0.1 mL) if you were using a Baxter Interlink on a stopcock. (Most of the posi-flush ports have no dead space.) Otherwise the drug was delivered into the infusing IV fluid and then into the patient when you gave it. Flushing wouldn't have made any difference. However, if your IV solution was INcompatible, then you'd flush the line pre and post to ensure no interactions occurred. And you'd be using the most proximal port on the IV line that you have. The only time I could see not flushing in this kind of scenario being a big issue would be with code drugs and adenosine where you want them in the patient NOW.

abundantjoy07, RN · Nov 13, 2007

While it's important to flush, I don't think it's as big an issue to where the famly would not want you taking care of the patient. It's not exactly gross negligence.

I never tell my patients I'm a new nurse. If they ask, I just tell them I'm new to the floor I'm on. And since I'm very young sometimes they will ask how long I've been nursing and then I'll tell them.

I often times balance this undesirable fact out by giving the family responsibility. I usually tell them that I need their help. (They generally perk up because they feel that they are now more "in charge.") I tell them that they are responsible for letting me know if anything is wrong, to remind me if something is not done or should be done, and to ask me any question they have. I tell them the last thing because even if I don't know the answer, it shows responsibility when I find it out for them and again gives them the "upper hand." I also tell them that I'll be giving meds at ___ time. And if I'm more than 30 minutes late it is their responsibility to page for me. It takes that edge off for them I think.

But I never tell them I'm new. I always go in with confidence and if I realize I can't do something then I tell them that I'm going to have to get some help because I'm unsure about what I'm going to be doing.

ginger58, ASN, RN · Nov 13, 2007

No, it's not a big mistake--it's a tiny one at best. Where I think the mistake is that your preceptor somehow got you off the case and wasn't able to stand up for you. Maybe she did her best, and if that's true, you are probably better off without this family and patient.

Head up, keep going and you'll be fine.

bubbly · Nov 14, 2007

Not remembering to flush the Dilaudid right away isn't that big of an issue. You shouldn't have used the excuse that you were new. You probably would have been better off saying something like, "Oh! Thanks for reminding me, LOL it's way too early in the morning, I really need my lunch break right now, geez I am having a dumb moment, etc." Just apologize/ laugh it off to the patient and let them know it was just a "moment" of forgetfulness and not a recurring problem with you. If you looked at it from the patient's and family's point of view, you would not want you or your loved one being cared for by someone who blames their mistakes from being new. Just learn from this experience and move on. I think all new grads have been in a similar position, including me. I try not to let my patients' families think I am new by exuding confidence in what I do (which will just take some time as you get more experience). And remember that some patients just have certain issues that you can't please. I have seen some experienced nurses on my med/surg floor back in nursing school who were asked to be replaced by grumpy patients. LOL at least you won't forget to flush again. :)

SuesquatchRN, BSN, RN · Nov 14, 2007

Families get really freaked at errors, however small.

Don't sweat it.

NurseNayin07 · Nov 14, 2007

Hi, OK today I gave a patient .5 ml IV Dilaudid push through an existing PIV with compatible solution. I forgot to flush. The patient pointed this out and I immediately did flush (explaining I was really new- maybe I shouldnt have said that, however, apparently the pt (and his family) complained to my preceptor, who then 'took over' the care for him for the day. I was really emabarrased, and later asked her, as well, did they not want me to care for him? She didnt really elaborate, but said she would just do it. IS this a huge, unsafe, med error? I was really perplexed by the intensity of the reaction, I guess.

Even if it is a compatible solution, I flush each and every time. I don't believe you made a huge error though. It happens. That kind of bothers me though what happened with your preceptor.. her taking over. Had you been off your orientation, you would have had to deal with that patient for the rest of the day. It doesn't seem realistic.. IMHO, she should have stood up for ya (and like the previous poster said, perhaps she did the best she could).

Mommy TeleRN, RN · Nov 14, 2007

I am glad this topic was brought up.

1) Let's say it's a med that is to be given over 3 minutes and it's 1 ml. If your fluids are going at > 20 ml hr then doesn't that give them a bolus of the med if you let the fluids flush the med in?

2) Let's say they have a PICC and no fluids going. And you instill 1 ml of med. That med is just sitting in the picc until you flush...so then should you flush it over 3 minutes?

suanna · Nov 14, 2007

I agree with JANFRN if you have a running fluid this serves as the flush. Accessing the line twice to give the med and then a flush would be more of an error from my viewpoint. As far as your preceptor taking over- its probably better for the family- The biggest mistake is telling them you are new at this. That does not instill confidence in you patients and there is no way to regain thier trust. Telling them you are new just served to make them more anxious.Your preceptor was the best option after that. A patient that feels confident that thier nurse is doing a good job is more compliant with the plan of care.

Pediatric Critical Care Columnist · Nov 14, 2007

I am glad this topic was brought up.
1) Let's say it's a med that is to be given over 3 minutes and it's 1 ml. If your fluids are going at > 20 ml hr then doesn't that give them a bolus of the med if you let the fluids flush the med in?
2) Let's say they have a PICC and no fluids going. And you instill 1 ml of med. That med is just sitting in the picc until you flush...so then should you flush it over 3 minutes?

1) In this instance I would be instilling a small amount of the med into the line, let's say 0.2 mL, and waiting 30-60 seconds then instilling another 0.2 mL, gradually instilling the volume of the med into the infusing fluid over the 3-5 minutes. I'm not putting the entire volume of the med into the line all at once. This is where knowing the volume of your IV tubing from the port you're using to the patient is important. If that volume is 5 mL, and your med is 1 mL, and your fluids are running at 20 mL, instilling the entire volume of the med at that port will give you an effective administration time of 12 minutes, or 1/5 of an hour. The infusing solution will dilute the med as it infuses. rather than pushing it unchanged into the patient, since it isn't a solid, right? Even giving a med IVP right at the site results in some dilution as you flush. Code drugs are given rapid IVP with a rapid large (10 mL) flush so that they get to the target quikly and in a concentrated-enough form to do the job. Adenosine is a perfect example. The half-life is so short that if you don't give it as proximal to the patient as possible and as quickly as possible, with both the adenosine and the flush needles in the port at the same time, you lose the oomph all together.

2) For this you could do a couple of things. You could dilute the med down to a low concentration and infuse it slowly over 3-5 minutes as I've described above, then flush it slowly over a minute or two to get all of the med to the patient. Then you'd flush the PICC as per your hospital's protocol to maintain patency. Or, you could do as you said, instill the med (if the volume is = or

Of course, that's all very nice, but you also need to assess your patient and their appropriateness for IVP meds in the first place. Some meds that can be given IVP will cause hypotension in some situations, and may be better given over a longer period of time, 15 minutes or so. Ranitidine is one of these and meropenem is another. If your patient's BP is kinda borderline, reconsider.

santhony44, MSN, RN, NP · Nov 14, 2007

I agree that saying "I'm new" is probably what freaked them out. I probably wouldn't say that.

My usual "excuse" when I do something dumb is "not enough circulating caffeine." :smilecoffeecup:

Then too I haven't been mistaken for a new nurse in a really long time!! :lol2:

HappyJaxRN · Nov 15, 2007

Nope. Not a med error. If you put it in a compatible soultion that is running, it will circulate into the patient's body. You don't need to flush. You didn't do anything wrong. In the beginning, I didn't elaborate as to how long I had been a nurse. I had been with the same hospital for many years and started the conversation out with that. No one needs to know how long you have been a nurse, but they always ask. I used to round up. Lol...if I was out 6 months, I would say, a year. Just over a year, I would say a year and a half. Lol....I never pretend to know an answer tho. If I don't know, I tell the patient that I will ask a more experienced nurse. Don't ever feel bad for doing that. I utilize more seasoned nurses all the time.

Don't feel bad. You didn't do anything wrong. :nurse: