Reality Shock: Nursing school vs the real world

[Nurse Beth, MSN]

Dear Nurse Beth,

My question is about patient safety. Nursing students are taught to use a filtered needle or a "straw" to draw up meds in a glass ampule that we've had to break up. The theory, obviously, it to minimize the chance of injecting small bits of glass into the patient. Earlier this week, while working in the ED, I saw a doctor break open an ampule of lidocaine to give to a patient in preparation for a chest tube insertion. The doctor did not use a filtered needle or a "straw". After the procedure, I politely asked him about it and he dismissed the practice as unnecessary. I'm curious as to your thoughts on this matter and how best to approach handling these incidences.

---

Dear How to Deal,

There's no doubt that using a filtered needle to remove medication from a glass ampule is recommended by the Infusion Nurses Society and the American Society of Health-System pharmacists. Glass ampules do pose a risk of particulate contamination, but in reality, using a filter to draw medication from an ampule doesn't always happen.

Compliance with the use of filter needles is spotty. Some hospitals use them; others don't even stock them.

You are dealing with Reality Shock: What's taught in nursing school versus the reality of practice in the real world. When conflicts present, you have to choose which battles to fight, and how best to fight them: ) Doctors are notorious for not embracing practice suggestions by nurses, although, who knows, you may have planted a seed for thought.

A good example is found around hand hygiene. It is appropriate to remind all healthcare team members to use hand hygiene in an atmosphere of collegial accountability, and it sounds as if you had that same respectful approach.

You can ask your nurse manager to provide filtered needles. If you open an ampule and it shatters, waste the medication and start over.

And keep asking those good questions (one reason why I love new nurses).

Best wishes,

Nurse Beth

[Donna Maheady]

I agree with you Beth...filters may not be stocked in all facilities.

I am so impressed with the nurse's courage to ask the doctor the question!

Keep on asking!!!!

[BloomNurseRN, ASN, BSN, RN]

I would be upset if my facility didn't stock filter needles and would be submitting an incident report if I saw anyone, doctor or not, drawing from an ampule without a filter needle.

[JayHanig]

I never used a filtered needle in my entire 18 years at the hospital bedside (at two different hospitals... one a huge teaching hospital). I don't recall ever seeing anybody else do it either. I don't know what a filtered needle even looks like, which ought to be a clue as to why I don't know anything about them. If the hospital wanted me to use them, they'd have stocked them and we'd have been inserviced on them.

FWIW, I never heard of a bad outcome due to injected glass fragments, though I have cut my fingers a time or two on an ampule popping it open.

[Lev, MSN, RN, NP]

If he was using lidocaine to numb the area before inserting a chest tube he may have felt it was unnecessary because he was not injecting into a vein. Nevertheless, bad practice. Always use filter needles if available for ampules.

[iPink, BSN, RN]

I work Postpartum and if I need to administer methergine IM (which is available in an ampule), I still draw it up with a filter needle. We also make sure our emergency hemorrhaging kit is stocked with filtered needles.

Maybe this can be discussed further in unit practice council meetings. You never know what changes in policy and procedures may happen when nurses come together with a unified voice about this subject.

[Gingercat]

I think worse than not using a filter needle is using one incorrectly. I found a syringe with the filter needle still attached that had been used to transfer a medication from a glass ampule to a bag of NS. I brought it up but was told it is not that big a deal. That nurse has a couple of decades of nursing experience. If the med was needed for an emergency then I get that, but this was just a routine med for the patient. These sort of things make it tough as a new RN.

[mursecope]

This was my thinking as well, but filtered needles are readily available at our facility, so I feel as though it should be standard procedure. Perhaps it if was an emergent procedure, I could see forgoing the filtered needle, but this was not. Thanks for the input!

[mursecope]

I agree. As a nursing student, I've been told repeatedly that there's "nursing school" and then there's the "real world." You're right, it is confusing at times as to what is and what is not acceptable. Thanks for weighing in!

[mursecope]

Thank you for taking the time to answer this question! I'm a second-career nursing student with a 20-year journalism career already behind me, so I am not at all shy about asking doctors questions. However, I know it can be hard for the majority of my younger classmates to approach a doctor and ask tough questions.

[Wrench Party]

I've seen filter needles aplenty on different medications (fentanyl and methergine come to mind) and I've also seen the concurrent safety needle available for either IM injection or IV push. We even used filter needles back in my research days when breaking extremely expensive chemicals out of their little brown light-sensitive ampules.

Drawing up medications from ampules without one? My nursing school instructors would have given birth to full grown cows over that. There's no reason in this day and age with the emphasis on needleless, safe systems that this should even be a question .

I would be going up the chain of command on this one if my facility didn't offer filtered needles.

[KateBSN]

I definitely feel overwhelmed at times with "real world" versus what I learned in school. Especially because different nurses will have different opinions as to what matters and what doesn't. I'm not sure what the solution is to this except that, if nurses in the "real world" are not following standards of practice, than we as a profession need to adjust the standards to reflect the reality of practice, or adjust our practice to reflect patient safety and known evidence. I'm sure that is wishful thinking, but it at least feels good to say it.