Hello all,
I am a nurse, seven years experience here. I am needing some advice as to how to mentally get past a mistake at work. Here is what happened. I work in home health, and was taking care of a patient with a catheter which is new for the patient and home health was ordered to teach catheter care. The patients urine output is bloody and when the previous nurse was with the patient, they noticed very little urine output and they irrigated the catheter and then it started to flow. They also showed the caregiver how to irrigate as well in case they needed to do so. So fast forward to the next day, I have this patient on my assignment and I am to go in and reinforce the irrigation procedure. Previous nurse gave me report and said that they taught the patient how to irrigate using the little blue leur-lok access area on the drainage tube and used a piston syringe with the little blue leur-lok removable access device tip that just pushes into the leur-lok. So I said okay I will reinforce that. I get into the home and what I am looking at is NOT what I thought I was going to find. I thought I was going to find a piston syringe with the grooves on the end that actually TWISTS into the leur-lok (like a NS flush twists into an IV), but instead found a regular piston syringe with the blue cap that pushes straight in. I have never irrigated this way before, always have just disconnected the catheter from the drainage tubing and irrigated that way, and I had a momentary brain fart and told the caregiver that the piston syringe is placed into the BALOON PORT to irrigate. Now I did not actually irrigate while in the home because the urine was flowing out well so it wasn’t needed, but I SHOWED the caregiver how to irrigate it step by step. Fast forward about two hours and I’m at the office charting and it hit me that I had told the caregiver to irrigate in the wrong port. I immediately called them and told them the correct way to irrigate and actually went back out to the house and made sure I showed them the correct way and that they understood. I told my charge nurse. And most importantly, he didn’t have to irrigate in those two hours and the patient was not harmed.
Now, granted I’ve never irrigated a Foley this way before, but I have inserted PLENTY of catheters. I just can’t mentally get past the fact that I would even consider doing what I told them to do. It scares me that I didn’t think of it until two hours later. I KNOW that port is for the balloon inflation, I’m just having a hard time mentally getting past this. I have never really made a mistake (not to my knowledge at least) like this. Any advice on how to cope with this would be greatly appreciated! Thanks!
