off orientation--first big mistake!!!

[bluelulu]

:(Last night was nuts. I work on a med/surg floor in a busy hospital. My unit is notorious for being "crazy". Anyways, I have been off orientation for about 3 and a half weeks and am totally on my own now. Getting back to last night I had 4 patiets w/ picc lines, one in detox, one with ATC chronic pain meds, and one(the poor guy) with a trach , a g-tube, a colostomy, multple stage IV pu's that needed dsg changes and on top of it a texas cath that wouldn't stay on and a wound vac!!I couldn't believe it. I handled everything OK for the first part of the the night til one of my co-workers, who was trying to help me out asked me about another pts IVF's. "does he need another bag?" I was like"There is no way his 1000 cc bag can be done yet!" I guess I programed 750cc/hr instead of 75cc/hr by accident!!!!!

I did an incident report and most importantly assessed his lungs and vs. There were faint crackles in his rt base. Other wise fine. Called the doc. got an order for lasix 20 mg iV and he diuresed (sp?) well. He was fine.

BUT I AM NOT FINE!!! I feel terrible and I can't believe this happened! He has a hx of CHF and kidney problems! He was getting iv abt's piggybacked and I must have messed up on his primary bag! I had so much more going on, he should have been the simplest pt.

Bottom line--I feel so bad and I am down a few pegs as a new, already insecure, new nurse!

thanks for listening...............

[RedhairedNurse, BSN, RN]

It's understandable that you feel bad, but don't be so hard on yourself, you're new at this. I bet it won't happen again....that's the great thing about mistakes, we learn from them.

[iluvivt, BSN, RN]

OK it happens and luckily it was some IVF and not Heparin or Lidocaine or some other drug. I have done this for 27 years and it has never steared me wrong. No matter how simple I think something is I always do this with my IVs. Before I leave the room and after setting up an IV....I start at the top (Bag) and work my way down to the site (wheter a PIV or CVC). I check everything...correct med and IVF....tubing dated...pump set at correct rate.....system closed and no contamination....drips labeled....site OK (PIV without redness swelling or pain..not outdated....CVC dressing CDI...no CVC complications....dressing not outdated. That way you can catch a mistake seconds after you make it and correct it. Also never never use the pump to prime your tubing via the pump unless it has a PRIME mechanism...too many nurses forget to re-set the rate. I saw more than one patient almost die b/c of this practice so I will not do it. I must deal with 40-50 IV set-ups a day so I have to be hypervigilant and all the patients are new to me since I go everywhere in the hospital doing IV therapy. Hang in there and you will develop systems and your own personal practice to keep your patients safe.

[PICURN74, ASN, RN]

I agree with the above posters, Learn from your mistake and forgive yourself. We are all human and we all make mistakes, fortunately it sounds like your patient was spared any significant harm and I am sure you will be a freak about checking your pumps from now on because of it.