Published Apr 5, 2013
SuzieVN
537 Posts
SNF. RN supervisor summoned (overhead, at about 0300) me to one of her rooms. She was attempting to insert an NG tube in an alert man, about 40, alcoholic, with varices. Told me she felt a 'blockage'. She was holding the tube as though it were a fork, and she was 'stabbing' something. She rammed the tube down, pulled back, then rammed it again- until blood exloded out the tube. I suctioned him really quick and the suction tubing, canister and filters became packed with blood. I ran out and called 911, came back told her "Get the **** away from him! What are you DOING"?. I was suspended, for allowing her, an RN, my supervisor, to be so incompetent. Was told I should have known she was incompetent, and should have 'taken the NG from her and inserted it yourself'. Oh, really. Yes, he died. She was 'asked to resign', because her son was the medical director of the place. The panic on that man's face is clear today, and that was 25 years ago. BTW- I don't think an LVN should insert NG tubes, it's as crazy as giving TPN. Out of bounds, my opinion.
nrsang97, BSN, RN
2,602 Posts
I was working ICU and was called to our stepdown unit so I could assist with a drip. This was a drip they were totally capable of running. I get there and under the Alaris they can't find it under secondary. I told them it is a drip. Three nurses looking at me like I have a third eye in the middle of my head. I told them drips are PRIMARY. They had it on IVPB tubing too. I made them go get primary tubing. They were having a hard time getting a BP. It was high on the machine. I listened and was getting somewhere around 160 for the top number. We didn't hang the drip, but I was scared that three stepdown nurses couldn't figure out how to hang a Cardene drip.
We had one nurse give a whole insulin drip thinking it was the pt dilantin. Denies that it was insulin. The pt was fine.
We had one nurse who hung blood with D5, same nurse put atropine drops in the eyes of a pt and didn't tell anyone. The drops were to go sublingual to control secretions. This pt suddenly had non reactive pupils and had to go to STAT CT, and ended up with an unnecessary EVD. When confronted about the situation she never owned up to it.
We had another nurse infuse a whole bag of fentanyl into a patient. Didn't report to the doc tried self treating with narcan. This pt ended up dying.
dirtyhippiegirl, BSN, RN
1,571 Posts
One of our PRN hires who supposedly had several years of ICU experience actually managed to somehow hook up IV tubing to a tube feed bottle and primed it. and this was with the new bottles that are supposed to be idiot proof.
NurseRies, BSN, RN
473 Posts
A nurse at my old dialysis clinic was to give all 48 patients their seasonal flu shots. He gave all the shots and didnt realize until the end of the day, that he had given them all pneumonia shots. 48 med error forms!! No one was affected, but he had to tell every patient what he did. They didn't fire him, but he had to switch to a new clinic.
One new grad nurse came running at me one day, screaming, "I think Mr. **** is bleeding out!!" I run over to his dialysis chair, I see him sitting there, snoring, reap even, a cup spilled under his chair, it was full of pink koolaid. Did this nurse really think the pink watery fluid underneath his chair was blood?!?! Not to mention, look at the patient!! He is completely fine!
SwansonRN
465 Posts
I wouldn't put an NGT in a person with known varices...if a doc puts in that order, he can do it himself. That whole scenario makes me shudder. What a gruesome way to die...
CrunchRN, ADN, RN
4,549 Posts
Wow. I mean yikes.
nurseprnRN, BSN, RN
1 Article; 5,116 Posts
One of my faves was the guy who bounced back to us (SICU) from the floor in screamingly bad acidosis. Turns out the nurse misinterpreted the order to "replace NG drainage IV q4h with NS" as "empty out the NG cannister and put it into the volutrol with some saline." OMG.
One of my other faves is the LPN in the PACU when I was a new charge nurse. She remembered that we always taped an O2 catheter to the ET tube of anyone who came in intubated, and extubated them as soon as they woke up enough to cough. I looked over and this woman was bucking and trying to sit up, and this LPN was holding her down and calling for sedation. I went over to see what was going on and discovered that the LPN had taped the catheter in there alright-- she covered over the whole end of the ET tube (so it would be good and secure), thus completely occluding her airway. I ripped it all off and extubated the lady, got her settled, and pulled the LPN into the office to ask her where she thought this lady would be able to breathe with her ET tube taped off. She looked at me pityingly and said, as if to a moron, "Through her NOSE." So we turned to the cut-away picture of the airways of the head and neck and I asked her to show me how that would even be possible. I swear she thought I was making it all up. THAT was pretty horrifying.
Sun0408, ASN, RN
1,761 Posts
I have seen a nurse attempt to give a fluid bolus with the pts primary fluid with 40 of K in it instead of NS. I have seen a new ED nurse put in a NG tube in a pt with known facial fx. NG tube went into the brain.. I have seen IVBP antibiotics given in TPN. Oh boy at the things I have seen. The bolus was stopped, the NGT was seen on CT once the pt was brought up to the ICU and the nurse was educated re: the TPN.
As far as a NGT on varices, oh no no no.. Not gonna attempt that at all..
ChristineN, BSN, RN
3,465 Posts
I have seen a nurse attempt to give a fluid bolus with the pts primary fluid with 40 of K in it instead of NS. I have seen a new ED nurse put in a NG tube in a pt with known facial fx. NG tube went into the brain.. I have seen IVBP antibiotics given in TPN. Oh boy at the things I have seen. The bolus was stopped, the NGT was seen on CT once the pt was brought up to the ICU and the nurse was educated re: the TPN.As far as a NGT on varices, oh no no no.. Not gonna attempt that at all..
Some antibiotics are actually compatible with TPN you just have to look it up first. Many are either compatible or compatible at the Y-site
Yes but she did it with secondary tubing above the pump not at the Y. We Y many things in. The pt still gets their TPN as well as other ordered medications. This day, they only got a fraction due to several antibiotics qx amount of hours.
Fiona59
8,343 Posts
An RN asking me to admit her patient. When asked why, she replied "Had a one night stand with him last week".
Uhm, keep your sex life out of my work load.
ktwlpn, LPN
3,844 Posts
BTW- I don't think an LVN should insert NG tubes, it's as crazy as giving TPN. Out of bounds, my opinion.