Read the order before hanging blood

[jannecdote]

An incident happened at our hospital that makes me aware, once more, of how easy it can be to do something that could possibly cost you your nursing license. I was not working when this happened, but heard all about it before I had even clocked in to work the next day.

We have no charge nurses on our unit so an RN is usually assigned to an LVN to start any blood transfusions or push IV drugs.

It was a busy day and an LVN finally got one of the RN's on the floor to start a blood transfusion for her on a M-W-F dialysis patient near the end of day shift on Tuesday. Early Wednesday morning the patient expired from fluid overload.

It turns out that the order in the chart said to infuse 2 units of PRBC's DURING DIALYSIS ON WEDNESDAY. The RN did not look at the order prior to hanging the blood via a central line. It is always drilled into our heads to make sure the consent for blood transfusion is signed, but I guess it is just taken for granted that we know what the order says.

This was an unfortunate situation for all involved. I will say this. There had been a lot of complaints about the LVN's job performance to administration but nothing had been addressed. An accident waiting to happen--and unfortunately for the RN involved--it happened to her.

It may be a basic nursing tenet, but please don't forget to look at an order when doing those extra duties for another nurse.

[Euskadi1946]

An incident happened at our hospital that makes me aware, once more, of how easy it can be to do something that could possibly cost you your nursing license. I was not working when this happened, but heard all about it before I had even clocked in to work the next day.

We have no charge nurses on our unit so an RN is usually assigned to an LVN to start any blood transfusions or push IV drugs.

It was a busy day and an LVN finally got one of the RN's on the floor to start a blood transfusion for her on a M-W-F dialysis patient near the end of day shift on Tuesday. Early Wednesday morning the patient expired from fluid overload.

It turns out that the order in the chart said to infuse 2 units of PRBC's DURING DIALYSIS ON WEDNESDAY. The RN did not look at the order prior to hanging the blood via a central line. It is always drilled into our heads to make sure the consent for blood transfusion is signed, but I guess it is just taken for granted that we know what the order says.

This was an unfortunate situation for all involved. I will say this. There had been a lot of complaints about the LVN's job performance to administration but nothing had been addressed. An accident waiting to happen--and unfortunately for the RN involved--it happened to her.

It may be a basic nursing tenet, but please don't forget to look at an order when doing those extra duties for another nurse.

Wow this is very unfortunate and it can happen to anyone. ALWAYS!!! ALWAYS!!! CHECK THE DR'S ORDER BEFORE GIVING ANYONE MEDICATIONS OR DOING TREATMENTS!!!!!!!!!!!

[sharann, BSN, RN]

Blood should be treated as a medication. I understand thae realities of floor nursing are really tough and that RN's trust the LPN's very much. However, I would check an order to hang blood(or give a med) EVEN when an RN asks me to. If it isn't my patient, I check.Period.Good to be aware of this, thanks.