Scariest thing you have found

Nurses General Nursing

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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...

Specializes in Med/Surg, ER, L&D, ICU, OR, Educator.
Originally posted by purplemania

When syringe outweighs pt. you should get suspicious.

:roll :roll :roll

Words to live by!:chuckle

Specializes in ORTHOPAEDICS-CERTIFIED SINCE 89.
Jay-Jay Scariest thing I've run across so far that I wasn't responsible for? Found 2/3 & 1/3 hanging with a blood transfusion,

I am ASSuming that if normal saline is 0.9 then 2/3 saline(?) is 0.6?

Glucose is traditionally 5% ? As in D5 NS?

So was this D 1.7 in 0.6 saline?

or do I have it backwards was it 3.3%Dextrose in 0.3% Saline?

JAY JAY????

No, it's referring to the volume of each, NOT the concentration! It's been so long since I've used it, that I'm not sure, but I THINK it's 2/3 by volume NS and 1/3 by volume D5W. (I did a search for this info on the net, and couldn't find it! In the community, we rarely ever use anything but NS.)

Specializes in Obstetrics, M/S, Psych.

That is interesting Jay-Jay, because I thought anything but NS was strtictly contraindicated with blood transfusion.

Specializes in Hospice, Critical Care.

I've never heard of 2/3 or 1/3 either.

Getting report in ICU on a fresh carotid endarterectomy patient...the patient was not maintaining his mean arterial pressure within the parameters the surgeon had specified. He would drop below and then he would exceed...drop below...exceed...drop below...exceed. Rather than using the nipride/neo that the doc had ordered for BP control, the nurse put the FRESH CAROTID in and out of Trendelenburg all shift. Fortunately, there were no adverse consequences. But, geez, yikes!

Rec'd an ER patient...alert & oriented elderly lady from home with dx of an MI. Moving her from the cart to the bed, patient is screaming in pain...abdominal pain that is. Belly is HUGELY distended and exquisitely tender. No work-up at all in the E.D. for the belly. Nada, not even a mention of it. I drop an NG tube and get immediately 600 cc dark red blood. Stat CT scan of the belly, woman codes in the scanner. (Family wants nothing done but MD cannot be reached for code status so we have to code her; twice actually--once AFTER she was already pronounced--but that's another story.) Rec'd the CT scan report later (post morgue) and of course she had free air in the belly. What a nightmare that day was. One of my angriest days on the unit. How did no one notice her belly in the E.D.?! (That doc is no longer with us.)

Zee

coded after a pronounced death? That is quite interesting..

Just yesterday as a matter of fact, I got called in to my NM's office because I gave a patient Elavil 10 mg - 4 tabs instead of the Elavil 100 mg - 4 tabs that was ordered. I honestly didn't see that second zero! Turns out that I was giving the RIGHT dose...it was transcribed incorrectly. Sigh.

Had a med aid give a 92 patient 25 mL of MS elixir (way way back when we got it in 200 mL bottles) instead of 2.5 mL. Patient slept for the first time in weeks and is alive and kicking today...just celebrated his 101th birthday!

Maybe not the scariest thing I've ever seen, but definitely the NASTIEST. I came in for my usual weekend shift on a subacute floor. It's Saturday and there is a new patient who was admitted on a monday. Prior to that the room had been empty for about a month. I walk into the room and the stench floored me. I spoke with the patient for a moment and tried to hide my disgust. Asked other staff members who had previously cared for patient why he would have a horrid cloud of funk taking over room. Only answer was he has N/V/D, infection, and refuses pericare and showers. Return to room look over patient. Inquire about possibility of showering, having linens changed, etc. Pt. refuses. Okay so I go to open the window to let some fresh air in. Pt does not object. Find one wound VAC lying in corner next to window. Wound VAC has container and tubing still intact. Wound VAC container filled with MOLDED BLOOD. Flies circling VAC. I grab a biohazard bag, removed tubing and container, begin to uncontrollably gag from odor. I run to the biohazard room and think I will pass out on the way. I can deal with odors, but I'm a first-timer when it comes to molded blood, the smell is far worse than road kill. Voila, contaminated equipment removed, problem solved. The kicker is that the pt had no wounds and that the VAC was left from a pt. that had been discharged weeks earlier. That poor guy was being blamed for stinking up the unit. Problem reported. Other nurses politely reminded to discard biohazardous waste appropriately etc. That was a few weeks ago. This week I came in and found two more contaminated VACs that were not in use in the rooms of 2 pts. who had been transferred to hospital. Luckily these hadn't molded yet. The patients were both due to come back. The containers just sitting there and the tubing lying on the floor. The closest explanation we can come up with is that the tubing is being "saved" for when the pts return because locating these particular tubing systems can be quite an ordeal sometime. This is starting to be a real nuisance to me!

Specializes in Home Health.
Originally posted by Hellllllo Nurse

Didn't you report it? Could you have written an anonymous letter to the family telling them the cause of the pt's problem?

This situation blows me away

Yes, I reported it, but that report doesn't go to the family.

I guess I could have done an anon letter, but that is not my style, and I was truly hoping this woman, who claimed to be a devout religious woman (doesn't matter what religion really, does it?), wouold "do the right thing." She did the right thing alright, for herself! I wish I could say it surprised me!

Our "Crash Carts" are to be checked daily. Opened once a week for complete inventory of all items-including medications contained in cart. Upon my turn to open the cart, I discovered that the Entire box of Cardiac rescue meds was missing. The pediatric med box was expired and the O2 tank was almost empty! The scarry part is that it's been like this for over 2 months! Nurses were just signing it off without checking it! Needless to say there were several "write ups" and mandantory inservices instituted.

Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

A patient recovering from a csection who would NOT arouse. NOTHING in report prepared me..and I was a first year RN. Turned out, she was hemorrhaging inside. I massaged her fundus and extracted SEVERAL clots that looked like one's liver!!! Yes, they were THAT big. Her pressures were almost unreadable, heart rate so fast and thready I could not count. Thank goodness, she came back fast. She responded to vigorous massages and IV boluses well. But her recovery was slower, as you might imagine.

It was just fortunate I happened to go to HER room first for assessments; I had a more recently-delivered patient to see. But "something" told me to go to room 263 first. So glad I did. I never ever forgot and never ever forgave that nurse going OFF for not being more sharp in her assessments. I learned the hard way you can take NOTHING for granted.

Specializes in Med Surg, ICU, Infection, Home Health, and LTC.

The scariest thing that I have seen happen since I started nursing was with one of the new RN graduates right after she got her license.

She had been left as charge nurse over a 46 bed medical floor and was the only RN on the unit.

At that facility only the RN's were permitted to handle anything that pertained to an IV.

The MD had ordered Lanoxin 0.25 mg IV now. She read the vials that each said 0.5 mg lanoxin and opened five vials and gave it.

The patient was moved to ICU but survived without coding.

I feel that the facility pushed the new grads and new hires out onto the units before they were properly trained and ready in order to boast that they had RN coverage back then.

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