Published May 30, 2003
What is the scariest thing that you have stumbled across after following someone else?
I found that a Dopamine drip had been started and left on all weekend on my medical floor that had staffing ratios from 1-6, and 1-10 at noc. And that with the drip, B/Ps had only been documented every 4-6 hours.
I also found a heparin drip going at 50 cc an hour. It was supposed to be 13 cc an hour. Someone hit the wrong button...
rachel h, BSN, RN
I have stumbled upon incorrect IVF, piggybacked antibiotics and pain meds that the clamp was never opened on so they never infused... and this was on patients who had serious bacterial infections... MRSA, PCP, etc. Scariest part is that is documented as given, or correct fluids infusing...
I've walked in on an extremely critically ill patient who's BP had been in the 80's, but she looked so much worse. That's when I discovered that her arterial line transducer was hanging by the side of the bed rather than at her armpit.
Her BP was really in the 60's.
I was quite angry.
Shoelace, I've walked into the same scenario and it is a crying shame particularly when this happens in an ICU isn't it.
I've run into more scary things on PCU because nurses are stretched further with less knowledge base...Dopamine hanging instead of Dobutrex, hypotensive patients on cardiac drips that nobody is monitoring, etc. Also scary to find someone titrating that doesn't know what they're doing with the drug.
When report starts out "Gee, wonder why he hasn't voided ALL DAY" when I'm coming on at 11p, and he's on a drip, I know how my night is going to go.
I have found drug allergies that were buried in the admission papers of the chart, but not posted on the outside of the chart.
Also caught a mistake when I nurse saw INR as a DNR and posted the DNR on the chart of a full code patient.
P_RN, ADN, RN
We suspected an RN on nights never hung the antibiotic minibags, just signed them out on the MAR. So we went ot initialing the bags we hung with date and time. The next morning there were the day shift nurses initials......GOTCHA.
I personally discovered a yankaur suction jammed into a patients trach tube. The nurse was a psych nurse who had come to acute care to "get skills up to date." That discovery was impressive to say the least.
RN always, BSN, RN
I once discovered a patient on a pca dilaudid pump had been getting 3X the dose ordered for 3 days! Amazing she was still alive. She had bad side effects from the drugs (twitching, jerking) Poor lady, once we got it straight we had to watch for w/d signs. She ended up being ok! Thank goodness!
VickyRN, MSN, DNP, RN
Pt on Colyte who ended up with a K+ of 1.8. Also, a full-code patient who was mistaken for a DNR and allowed to expire when he went into respiratory arrest.
A new grad hung an insulin drip without using a pump. She asks, "How do you regulate the amount of insulin?" The bag was hanging into the patient, without the use of a pump! I almost pooped right there. The patient turned out fine, though! Close call....
Back in 77 when I started with hospital nursing, there WERE no pumps. We hung everything to gravity.
About a year or so later we got little plastic dial-a-flow restrictors but they didn't work any better. We hung TPN, Chemo, insulin, morphine what have you. NO pump. And we did OK.
In an LTC, the night nurse supervisor noticed this bright yellow IVF infusing and asked the nurse (agency newbie) what it was. Nurse abruptly replied, "KCl!"
The nurse dissolved K Chlor (powdered p.o. KCl in a packet ) in water, aspirated it with a 10cc syringe and mixed it in the patient's D5W 1000cc IVF.
Her rationale, "I can't find the bottle for the IV KCL but I used bacteriostatic water to dissolve the powder." Nurse sent home. Agency removed from registry.
Poison Control was notified. Their response, "Huh???" "Never heard this one before, but please keep us updated."
Patient experienced no adverse effects.
purplemania, BSN, RN
Found 30 blood in buretrol of pedi patient. Line dry so long it backed up. You can imagine what the IV site looked like.
Also had nurse draw up 24 hr dose of phenobarb into 60cc syringe (instead of dividing by 4). When syringe outweighs pt. you should get suspicious.
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