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Discussion

nurse's error--yikes?

Hi,

I am a new student nurse and today I followed a nurse during her shift. At the end of the day she noticed that the fluids that had run all day were wrong. The patient was hospitalized for intracranial hemorrhage (admitted 4 days prior) and had a massive headache with some spatterings of confused behavior on previous days.

The correct fluid was supposed to be D5 normal saline with 20 meq of KCl. The fluid that was given was D5 half normal saline (.45), no KCl. All I can find online is "don't give hypotonic fluids" for risk of cerebral edema. I'll never be on that unit again and have no idea what will happen to this patient. Anybody have any experience with this?? The bag was more than half empty but who knows how many bags had been run!

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Oh my goodness!!! Did you tell your clinical instructor? I am in my last semester of nursing school and I have more than once questioned things that didn't seem right. Everybody makes mistakes; first check the MD order (as you did), then show it to your preceptor. If he or she doesn't seem concerned (which I hope wouldn't happen), then talk to your clinical instructor. If your instructor cannot be found for some reason, talk to the charge nurse. That's just what I would do. You have to be your patient's advocate.

Even though you're not going to be on that unit, still talk to your instructor. He or she can still intervene.

For those of you who are preceptors--THANK YOU for doing waht you do! We students appreciate you!!!

Actually D5.45NS is isotonic but still that was an error to hang the wrong bag. Stuff like that happens sometimes in the real world of nursing, we just hope it doesn't do harm and strive to learn from those events.

That's why assessing everything attached to the patient is as important as assessing the patient. You must treat the IVs, catheters, etc., as part of the patient. Always check the IVs hanging with your initial assessment; if you catch it part way through your shift, you are as responsible as the individual who hung it in the first place.

At the end of the day she noticed that the fluids that had run all day were wrong.

Just wondering what this nurse did when she realized her error.........

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