Scariest thing you have found

Liddle Noodnik · May 31, 2003

Originally posted by Jay-Jay
Found 2/3 & 1/3 hanging with a blood transfusion

What's this mean please?

Probably so obvious...

Jay-Jay, RN · May 31, 2003

Zoe, you NEVER EVER hang blood with anything but N.S! It's just not compatible, and will cause the cells to lyse or maybe even coagulate. Luckily, the 2/3 & 1/3 was not actually turned on to run with the blood, but had been used for flushing at the end of the transfusion.

Dayray, RN · May 31, 2003

I came in, one mourning and while doing my AM assessment the patient c/o pain in her backside. I turned here over and found a blue plastic stem about 1 inch long sticking out. The patient didn't know where it had come from. I went back to the chart and looked for some indication of what this was.

Then it hit me it was the plastic skewer used for vial access (needeless system). Patient had received an IM the night before for pain and the nurse didn't know how to use system. She had to be pretty dumb because the vial access things are flexible plastics with an arrowhead at the end.

Called the doc (who went ballistic) a resident came in used lido and removed the blue stem. The patient was scared out of her mind it really shook her confidence in our care.

night owl · May 31, 2003

Not the scariest, but certainly the most cruelest. Worked psych one night. The next morning, a pt c/o his feet were hurting so bad and would it be ok for him to have breakfast in his room. (He had gout). Charge nurse said, "NO, it's not allowed!" So the pt ever so slowly and in a great deal of pain shuffled to the dinning room. The kitchen aid went to hand him his tray and the charge nurse said, "'Oops, breakfast is over" and made the kitchen aid put his tray back. I asked her what was that all about, and she said, "He took too long." Oh really? I gave him his tray when she left the room. Explained what happened to the Unit manager when she arrived, wrote her up and the ***** was suspended for three days! Thought she should have been admitted to the psych ward for that little stunt...

casper1 · May 31, 2003

All these storys are horrifying. I'm interested in knowt the ratio of nurses to patients was at the time of the incidents. The scariest thing I remenber is the night we had only two nurses for 33 patients on a acute medical floor.

Liddle Noodnik · May 31, 2003

Originally posted by Jay-Jay
Zoe, you NEVER EVER hang blood with anything but N.S!

Yes, I am aware of that, but still don't know what 2/3 and 1/3 is. Is that the percentage of sodium?

LilgirlRN, ADN, RN · May 31, 2003

This happened to my son.. he's in Florida with my mom and my nephew when he was 18. Open tib/fib fx, worst xrays I've seen and I work the ED. Talk to the ER nurse in Florida at the county hospital they took him to because he didn't have his insurance card on him. She assured me that the orthopod was 'the best". They took him to surgery, he was just coming back to his room when we arrived. I asked to see the post op films, they were no different than the pre-op!! Took him home the next day and went to see a real orthopod, had to wait 5 days for surgery to put a titanium rod in his leg because it was infected. All they did in "surgery" in Florida was swab the thing out with betadine and put a posterior splint on!!!

shoelace · May 31, 2003

Yeah, I'm not aware of what 1/3 and 2/3 are, either.

Thought of another one. Well, not that I found, but it was a near

miss. I had a pt. on an insulin gtt that the pharmacy was mixing.

One night as I was checking the bag against the care plan with

another RN just about ready to hang it, pharmacy calls

and almost literally screamed "STOP!" in my ear.

Turns out the (new) pharmacy tech had mixed the bag

(supposed to be 100u Reg Ins in 200cc) and checked

it with the pharmacist, but after the bag was sent

up, the phamacist noticed a few more empty

bottles of insulin laying around than should have

been...

This was years ago, but I think I remember that the tech

actually injected 1000u into the bag.

Yikes.

nicudaynurse · May 31, 2003

Wow these are scary stories!!

In the NICU I took care of a baby that had TPN and Intralipids infusing and the rates were reversed. When the lines were changed the nurse put them in the wrong chambers so the TPN was going at the prescribed Intralipid rate and the Intralipids were going at the prescribed TPN rate. This went on almost the whole 12hr shift until the baby became symptomatic and the charge nurse traced all the lines and discovered the problem. When blood was drawn from the UAC it was a whitish color. The baby did survive, but barely. The nurse had to report to the state board. It was a mess.

It just reminds as that we are all human. Nurses have that added stress that a lot of other professions do not have because if we make a mistake it can kill or harm our patients whereas other professionals may just lose the company some money.

I know if I made a serious mistake that caused death or disability to one of my patients I would probably have to leave nursing.

PediRN · May 31, 2003

PICU nurses gave a baby 800 mg of Gent instead of 80 mg. This seems like an honest mistake until one considers that Gent comes in vials of 80mg/2ml, meaning the nurse had to draw up ten vials of Gent. Kid wound up having major hearing loss.

sweetbaby · May 31, 2003

a very cold, very purple, very stiff 65 yo full code that had just been checked 15 min ago by the night NA going off duty. :confused:

KaraLea, LVN · May 31, 2003

Just the other day, we had a pt become unresponsive (still breathing and with a pulse though). We had been told two days straight in report that he was DNR, but when the RN checked the chart, she found that he was actually full code. Luckily, he was just having a seizure and came back "awake" after a couple of minutes.