Nurse in Spain Makes Fatal Mistake in NICU

dawngloves, BSN, RN · Jul 15, 2009

Holy cow! I guess they don't use the feeding system we use at our facility. (Not interchangeble and colored florescent orange)

LUNISE · Jul 15, 2009

Its sad that he lost both his wife and son due to two separate causes. But his son's death could have been prevented for sure...sad.

rachelgeorgina · Jul 15, 2009

What's worse is he's only 21. He's got a whole world ahead of him. I'm only 20 and I'm not even contemplating weddings and kids.

This is really sad. But.. it is beyond me how a woman with peds and critical care experience can miss an NG and "feed" a baby through their IV lines...

BabyLady, BSN, RN · Jul 15, 2009

Hospitals in this country generally have "check offs" when you start.

Now we know why.

dawngloves, BSN, RN · Jul 15, 2009

This is really sad. But.. it is beyond me how a woman with peds and critical care experience can miss an NG and "feed" a baby through their IV lines...

Hospitals in this country generally have "check offs" when you start.
Now we know why.

I've heard of crazier things done by experienced nurses. You can have all the expereince in the world and all the "check offs" that will fit on a sheet of paper, but all it takes is one distraction to cause a horrific mistake. I can promise you, that if that hospital had had an exclusive enteral feeding system, this would never have happened. It is impoossible to hook it up to any IV set. If your hospital doesn't have one, look into it. If you think this would never happen to you, think again.

babyNP., APRN · Jul 15, 2009

I heard about this from some non-nursing friends in New York the other day. Oh man. That poor family.

BabyLady, BSN, RN · Jul 16, 2009

I've heard of crazier things done by experienced nurses. You can have all the expereince in the world and all the "check offs" that will fit on a sheet of paper, but all it takes is one distraction to cause a horrific mistake. I can promise you, that if that hospital had had an exclusive enteral feeding system, this would never have happened. It is impoossible to hook it up to any IV set. If your hospital doesn't have one, look into it. If you think this would never happen to you, think again.

.....but it wasn't the point of the story.

It wasn't an experienced nurse that made the mistake, it was someone brand new and it was their first day on the floor.

That made this particular situation avoidable.

Where was the supervising nurse? Or do they turn them lose on the floor in that country right after graduation from nursing school?

babyNP., APRN · Jul 16, 2009

Right, but the article reports that this person had experience in critical care and pediatrics.

In which case...how does one do something like that? The only thing I can think of is if the nurse thought the formula was intralipids.

dawngloves, BSN, RN · Jul 16, 2009

.....but it wasn't the point of the story.
It wasn't an experienced nurse that made the mistake, it was someone brand new and it was their first day on the floor.
That made this particular situation avoidable.
Where was the supervising nurse? Or do they turn them lose on the floor in that country right after graduation from nursing school?

This situation was avoidable no matter who the nurse was. And for the record, as mentioned, it was an expereinced nurse.

NeoNurseTX, RN · Jul 16, 2009

This happened in one NICU I worked at. Good nurse, but sometimes we just get into a routine. The baby was okay.

RainDreamer, BSN, RN · Jul 16, 2009

Holy cow! I guess they don't use the feeding system we use at our facility. (Not interchangeble and colored florescent orange)

Awesome system btw, we use the same thing.

My heart goes out to that family.