Sick

Saasy · Dec 9, 2013

I should add the wrong line had nothing hooked up to it- so the error/stop messages were about air

Esme12, ASN, BSN, RN · Dec 9, 2013

((HUGS)) nursing is a constant learning process...learn from this to mkae you a better nurse!

ausrnurse · Dec 9, 2013

Sorry can you explain further? What do you mean by wrong line and programmed wrong?

We have 2 different types of pump giving sets - a non-filtered giving set for regular medications and a filtered giving set (with 2 spikes) for blood. As far as I'm aware, in this day and age, filtered giving sets are only an extra precaution for blood and the 2 spikes are so that we can prime the set and flush it with saline once the infusion is done. I may be wrong about the filters (someone else feel free to jump in), but certainly in an emergency we use gravity or bolus sets which do not have the filter in them.

It doesn't sound like anybody was harmed, and the worst that happened was a bag of blood was wasted (which is bad for the budget, but there are errors that cost much, much more), and by your own admission, other nurses have made the same mistake. I would try not to lose sleep over it, I'm sure you won't let it happen again :)

Saasy · Dec 9, 2013

This was a filtered giving set with 2 spikes. We programmed it as a secondary line instead of a primary line and there was no secondary line so it drew in air and kept beeping. No harm done though but it was silly. I should've known better myself and if the senior nurse hadn't said anything it wouldn't have happened.

nurseprnRN, BSN, RN · Dec 9, 2013

You don't need to discard a unit of blood because it got saline in it. We dilute units of packed cells with saline all the time to make them flow better. No reason at all you couldn't have taken it off the wrong spike and put it on the right one, or set the IV to run the secondary line, either. Unless I am completely missing something in your description.

Been there,done that, ASN, RN · Dec 10, 2013

No, SHE did not get you to program the pump for the wrong line.

YOU programmed the pump for the wrong line. If you have not had dual solutions to infuse by this time in your career, you should have sought out the opportunity to do so.

Review your pump, practice with saline bags, go to nursing education for assistance.

Take responsibility for YOUR practice.

Saasy · Dec 10, 2013

Yes you're right which is why I felt so guilty because as I said in my post I should've known and figured it out. I have had plenty of opportunities with the pumps also which is why I felt ridiculous too. I guess it was partly just nerves with family there and the other nurse so insistent that just made my mind go blank. I did learn my lesson and figured out what the problem was. The main issue for me is it seemed so silly plus the blood was wasted. Ugh some days.

Been there,done that, ASN, RN · Dec 11, 2013

Grn Tea, I'm wondering if the blood was just diluted, or the process took over the 4 hours that is allowed to use the blood. Which was it OP?

Esme12, ASN, BSN, RN · Dec 11, 2013

If saline goes into the bag you can still infuse it so I am not sure.

Pudnluv, ASN, RN · Dec 12, 2013

Everyone makes mistakes. No one was harmed. All you can do is learn from this. I am willing that you will become a "house expert" on the use of the pumps and blood administration. Don't lose sleep, just don't do it again.

KelRN215, BSN, RN · Dec 13, 2013

You don't need to discard a unit of blood because it got saline in it. We dilute units of packed cells with saline all the time to make them flow better. No reason at all you couldn't have taken it off the wrong spike and put it on the right one, or set the IV to run the secondary line, either. Unless I am completely missing something in your description.

I had the same thought, I'm not sure why the blood had to be discarded... unless it was over the allotted time to have it hanging by the time they had the second set primed?

OP, don't lose sleep over this. It's not the first time a unit of blood has been wasted and it won't be the last. I once had a kid all set to get blood- premedicated, blood spiked and I went in to hang it and his temp was 39.3. At that point, the team decided they wanted to hold off on the transfusion- I forget if it was because they wanted to broaden his antibiotic coverage and didn't want to wait until after the blood was done to start or if they were worried that a subtle transfusion reaction would be missed if he was febrile when we started the transfusion but, either way, I had to send that unit back to the blood bank to be wasted.