The newspaper article (I will keep looking for the link for the article) said she accidently hooked up the epidural bag instead of the pennicillan bag for IVPB, she started seizing and died 2 hours later.
Apparently the pt. was very nervous about her epidural, the nurse took the epidural bag out of the pump and showed it to the patient. She apparently set the epidural bag right next to the IVPB bag of penicillan she was going to hang and got them confused.
The hospital uses a bar code system for meds, supposed to scan the med, nurses ID badge and the med before giving the med. Patient's ID band was not on the patient but still in the chart.
I feel bad for the family, but also feel terrible for the nurse who has been put on administrative leave. This could also impact the hospital's medicare standing as well.
Our epidural meds are in glass bottles, not bags at all, no way to mistake them. Plus they are on the other side of the bed by themselves to keep them separate. We do not hang them anyway, the doc does.
I don't know if I am 'legally' responsible for actions of LPNs and CNAs - but they do work under my license - I always assumed it was the same thing. If they screw up, it's on my license. Could someone explain the difference to me.
You aren't responsible for the LPN, they have their own license and don't work under yours. They *MAY* work under you as far as rank and supervision, but you aren't legally responsible for the LPN.
You are responsible for the CNA though, because they are unlicensed personnel.
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
Our epidural bags and abx bags look nothing alike either. PLUS the epidural bag has a BRIGHT PINK label that says: "caution epidural" on it. They really look different. PLUS the abx actually have to be mixed into the bag (there is a little vial attached) before you give them. Hopefully, this is enough to trigger us not to make the same mistake. But I have learned, never to say never and be very careful in all I do. Errors happen; some can be deadly.
our epidural meds are in glass bottles, not bags at all, no way to mistake them. plus they are on the other side of the bed by themselves to keep them separate. we do not hang them anyway, the doc does.
how tragic...
same here, and we have a crna who hangs the epidural bottles.
Specializes in Nurse Leader specializing in Labor & Delivery.
Oh wow. How awful. Our epidurals are in a syringe that are loaded into a separate pump that looks TOTALLY different from our regular IV pumps. There's no way that could happen in our facility (plus, I don't even TOUCH the epidural pumps, other than to turn them off, so no risk of removing the syringe to show to the pt).
at my old hospital, we only used pre-mixed epidural flasks, that looked different, felt different and were different to anything else. and just to make it doubly clear, a fluro yellow sticker with EPIDURAL INFUSION in big black letters, as well as the date, time, prescriber, and the two nurses who hung and checked the bag was slapped on every one.
epidurals ran through a specific pump that looked different and was different to anything else.
and epidural tubing was also different, it had a yellow streak that ran down it, and that tubing was only ever used for epidurals.
all this contributed to much less med errors, and everyone from the top brass to the new kitchen staff knew what an epidural looked like.
I thought AWHONN guidelines state that RNs should not "touch" running epidurals for labor patients. I traveled to a place once where the labor RNs hung the meds & set the pumps. I refused to do it. I asked the anesthesiologist to program the pump & he didn't know how!
It bothers me that RNs pass the responsibility onto the CRNA or MD. They can make a mistake just as easily. We should instead be looking at ways to improve our own practice.
We have a new MDA that I worked with for the first time last noc. Called him to notify him of a low BP (both mom and baby asymptomatic) and he asked me to turn down the pump. If other threads had not taught me the lesson, this tragedy certainly has.
I nicley told him I do not touch epidurals, but in my mind I was screaming - NO WAY, I WILL NEVER TOUCH AN EPIDURAL, I WILL NEVER TOUCH AN EPIDURAL, I WILL NEVER TOUCH AND EPIDURAL!!!!!!:trout:
I thought AWHONN guidelines state that RNs should not "touch" running epidurals for labor patients. I traveled to a place once where the labor RNs hung the meds & set the pumps. I refused to do it. I asked the anesthesiologist to program the pump & he didn't know how!
That is exactly what the AWHONN guidelines states. I too worked at a hospital where the nurses placed the epidural bags in the pump, programmed it and started it as well we turned it up or down....the anesthesiologist had no idea how to run the pumps either. The staff nurses there had no problems disregarding guidelines but I refused to...needless to say I don't work there anymore. I would caution any OB nurse to think twice before touching an epidural infusion other than to turn it off...if something were to happen, in most cases you would stand alone in a court of law.
Specializes in Nurse Leader specializing in Labor & Delivery.
It bothers me that RNs pass the responsibility onto the CRNA or MD. They can make a mistake just as easily. We should instead be looking at ways to improve our own practice.
We "pass the responsibility" because it's not within our scope of practice to manage epidurals. That's why CRNAs and MDs have much more schooling and get paid a lot more - because they have a greater responsibility. If I'm going to take on the responsibility that rightfully belongs to the MD, then I darn well want his paycheck, as well.
This is a horrific tragedy. A lapse in care by one nurse has taken one life,devastated many others and sullied the reputation of an otherwise excellent hospital.
The scanning of medications and a patient's barcode represents an over reliance on technology to assure patient safety. Ultimately,it is the nurse and not the scanning system that failed. The epidural medication was given by the wrong route. It is irrelevant that it wasn't scanned properly--the scanning machine doesn't perform the administration.
This was not a system error,it was a nurse error. The epidural pump is nothing like an IV pump. Epidural tubing has a yellow stripe on it. The epidural bag had a bright neon pink sticker that says "CAUTION EPIDURAL". How so many precautions were missed is beyond my comprehension.
When this story came out,I felt sick about it for days. I work with plenty of epidurals,as well as hundreds of IV meds. Just one momentary lapse of concentration while administering medications,just one violation of one of the 5 rights,could prove fatal for the patient. This thread should go in to every single forum,because in the end we nurses are the ones administering medications to patients,we are the ones responsible for their safety,and we all need to recognize that mistakes can occur despite the best-made plans to prevent them,and that these mistakes can kill.
Suebee6
68 Posts
Our epidural meds are in glass bottles, not bags at all, no way to mistake them. Plus they are on the other side of the bed by themselves to keep them separate. We do not hang them anyway, the doc does.
How tragic...