New nurse made a mistake!

Nurses New Nurse

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Hi all,

I've been working as a nurse since July (I graduated in May 07). I started at a small community hospital ICU. I work the 7p to 7a shift and have been doing very well. Just when everything is going so well I was doing a PICC line dressing change and accidentally pulled it out a at least 4 inches (which is a LOT for a central line). The dressing was so saturated with old dried blood that the old dressing was difficult to take off, and I must have pulled it even though I was extremely careful. I immediately cleaned and dressed the site appropriately, told my charge nurse, and called the doctor to obtain a stat chest xray. Then, I gave report to the oncoming nurse who had had the patients the previous day. When I told her what had happened, she looked at me as though I had run over 2 puppydogs. I know that its a big deal, but things happen and it could have happened to anyone, right? Am I wrong to think this way? I did what I could and acted appropriately after the event. Let me know what you think.

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You did the right thing. People pull out IV's everyday. Good thing is that you acknowledged the mistake and did not attempt to conceal it, which could have been fatal. Learn from your mistakes so you won't do it again.

Just remember....everybody makes mistakes, from new nurses to seasoned nurses.

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Specializes in Utilization Management.

Stuff happens. You handled it the way I've been taught to handle it. You reported it to the proper authority and you followed up appropriately.

You might want to ask your charge nurse if there was anything you could have done differently so that you might learn and thus not repeat the mistake.

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Specializes in Emergency.

Hi there!

I am a new grad as well. Since I started working, I have had to accept the reality that "doo-doo" happens. The important thing is how you handle it. You handled this situation in exactly the right way. Don't worry about what the oncoming nurse thinks of you. This totally could have happened to any nurse, regardless of experience. Yes, it's scary, but I assume the pt was ok, and the PICC was either still patent, or was changed. I have done lots of PICC dressing changes, and they sometimes do stick, and are hard to remove. A PICC that is not sutured requires careful handling, but can still be pulled out by accident even when you are careful. Don't beat yourself up over it. Take is as a learning experience and move on. In the future, you will remember this when you change PICC dressings and be even more careful.

Besides, think about all those confused patients that pull out their PICC lines themselves! Most of the time they are OK, but it is definitely scary to walk into a room, and see the line on the floor or bed, and a huge hematoma or puddle of blood!

One thing that may help you the next time is to use the sterile antiseptic solution ( we have wands with chlorhexadine) to moisten the dressing. Makes it easier to remove. Also I always have one hand (sterile glove) on the line to immobilize it while removing the old dressing.

You responded the way you should have to a scary situation, and that is all that matters, don't let anyone make you feel bad for what happened.

Whether you are new like me or have years of experience, everyone makes mistakes.

Good luck, you will be fine!

Amy

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Specializes in NICU, PICU, PCVICU and peds oncology.

:yeahthat: The oncoming nurse's facial expression was probably related to all the potential nasty things that could have happened, and not so much that it was you who happened to be the one changing the dressing. You totally handled the event correctly. The important things are that you didn't panic, you informed all the appropriate people, checked placement post and took responsibility. I know that next time you change a PICC dressing you'll be looking for the things that contributed to this event and planning ahead. Good job!

I work PICU and we have lines, NJ tubes, foleys, endotracheal tubes lying in the bed every once in awhile. I had a kid pull out a sutured central line from his neck... don't know how that could have happened with his hands restrained, but there it was. He was fine and we decided to leave the line out. I've also had a little person pull out an intracardiac line with her ever-so-nimble toes... Stuff happens.

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Specializes in Post Anesthesia.

"....even though I was extremely careful"

Apparently not careful enough. I would have most likely given you "the look" when you told me that in report. Sorry but a half an inch is a lot- stop pulling and try something else. To have pulled it out 4 or so inches is careless. Live and learn. No one is perfect and I'm sure it won't happen again soon. You did take the appropriate action which means a lot- some would have just tossed on a dressing and hoped no one would notice. By taking responsibility for your error you did the professional thing but "...it could have happened to anyone, right?" It could have happened to anyone who wasn't as careful as they should have been as I'm sure you will be in the future.

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You're absolutely right. I do feel terrible because I usually dont do things like that and dont understand how I could be so careless. It definitely won't happen again. And, my patients have enough problems, knowing that I could have contributed to them is aweful. And, no one else seems to make mistakes like this on the floor in which I work because most are seasoned nurses.

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Specializes in Operating Room Nursing.

Don't beat yourself up over this. You have the right attitude, you did the right thing and don't listen to ppl who criticise you too heavily. Either they are perfect, intolerant or just plain lucky not to make a mistake. PICC line dressings can be difficult. At my HCF they don't suture PICC lines as they do CVC so it can be very easy to dislodge it when your taking off the old dressing and when there is lots of dried blood.

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it sounds like you handled the situation very calmly and with a clear head which is one of the qualities that make a good nurse!!

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"....even though I was extremely careful"

Apparently not careful enough. I would have most likely given you "the look" when you told me that in report. Sorry but a half an inch is a lot- stop pulling and try something else. To have pulled it out 4 or so inches is careless.

In 22 years I am sure you have never made any kind of mistake?

We have to understand that mistakes and accidents are the normal part of life. They have always happened and will unfortunately keep happening. Now if you make a lot of mistakes or a pattern develops and you are constantly making the same mistakes over, there may be a problem.

In this situation there was hardly any danger to the pt. Think about how long a picc line is. I'm sure it was still patent, and if not. like another poster said, they can replace it.

I do not think you were being careless. I'm sure that next time you'll remember this and do it a little differently or maybe ask for another set of hands. I think the most important part is that you handled the situation professionally and didn't just leave it, now that would have been careless.

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Specializes in Cardiac Telemetry, ED.

In this situation there was hardly any danger to the pt. Think about how long a picc line is. I'm sure it was still patent, and if not. like another poster said, they can replace it.

Actually, that's not quite the case. If this is their only IV access, and it cannot be used because the tip is no longer in the SVC, then it could compromise their safety if they are in need of any kind of life saving infusion. I don't know if you've ever watched a PICC line insertion, but it is no small task, and there are risks involved. This is why patients have to sign a consent for PICC placement. It is an invasive procedure.

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You are exactly right on the access issue, there is always some danger, I didn't mean to imply that there was none. The pt is probably a hard stick, or has a chronic condition that warrants a picc. I don't know, however in this situation the pt was not harmed and everything turned out ok. If the picc was pulled back 4 inches that would put it in the subclavian vein, still patent for emergencies. The intent of this is for the new nurse not to beat herself up about this. It happened, everyone is still alive, and I'm sure she learned a lesson.

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