Tracing Lines Each Time

Coffee Nurse, BSN, RN · Jun 23, 2015

I am wondering how many hospitals out there train their nurses to the expectation that you trace your IV lines every time you administer something through that line? The purpose would be to trace the line from patient to the pump or syringe to verify that you are administering the medication exactly where you intended to. Thanks

Er...of course you make sure you're administering into the right line? Does anyone actually just take a random syringe off a pump and inject something into the line?

ScrappytheCoco · Jun 23, 2015

If I have anything going other than fluids I label the lines with a sticker near the port as I hang them. Especially for critical drips. I've never worked at a hospital that required it, just a good habit taught to me by my first preceptor as a new grad.

AJJKRN · Jun 23, 2015

I think some things are just expected of us as nursing professionals to perform or know, such as labeling/tracing multiple lines, etc. This is just like having the expectation of following the five rights (or is it six now) of medication administration, it's just an expectation that it is done with each Pt and every med, every time. What I haven't seen as much lately as I would expect to are nurses checking for compatibility/incompatibility before med administration...or knowing what the meds drug class is, expected outcome, etc... :eek:

GuEsT78 · Jun 23, 2015

I was a nurse tech on a pediatric Hem-Onc unit, where our patients typically had complex, multi-pump, multi-bag IVs. Whenever possible, I checked every detail of the IV from the bag to the patient at every opportunity, generally every time I entered a room on night shift. It's all too easy to make mistakes in a dark room, particularly for a nurse that's handling up to seven patients who all have complex IVs.

There was a reason for that precaution. We were one of the first hospitals in the country to adopt the Hickman line for pediatric oncology patients and at the time we were having serious problems with air embolisms in those lines. I wasn't giving the meds. The nurse I worked with did that. In addition to my other duties was looking for any mistake that could lead to an air embolism, given the complex choreography of chemotherapy and its aftermath (blood products, antibiotics, and some anti-virals). Unfortunately, the air sensors on our IV pumps were separate from the pump itself, so the pump could be putting air into a patient while the sensor sat as silent as death on an unused line. You can read the details about how such errors can occur in the fourth chapter a book that's posted for reading here:

https://indd.adobe.com/view/c1892142-ecf8-4621-a7a9-eee8f0ce19ab

For me, the most important "when" rule comes afterward, at least for medications given by pump. When you've made any change to an IV, then, before you even think of leaving the patient, trace the entire path from bag to patient, checking every detail. It's changes made wrongly that will get you into trouble. That is either things you should have done but didn't or did do but shouldn't.

Situations can vary from hospital to hospital and patient to patient, so I'd suggest thinking through what you're doing in each of your treatments and spotting every potential error. Where you need to be particularly careful, are situations where those errors can be made.

If you read that chapter four above, you'd discover our situation. Yes, the mistake that caused an air embolism seemed unlikely. It only happened when several mistakes were made at the same time. But those mistakes were ones of omission not commission. In a hurry, it is easy to forget to do several steps than it is to do all of them wrong. In some 26 months at that hospital, I caught four embolisms, so they certainly weren't rare.

I've often thought that hospitals should have the equivalent of the bright-colored "Remove Before Flight" tags on aircraft. When a nurse makes changes to an IV, she's taught to flip a tag so a bright yellow "Check IV" shows. She doesn't leave the room until she has checked the entire IV path. Only then does she flip the card over to a green side that says "IV OK."

One more suggestion. Well-established habits make it easier to get something right all the time. If you need to do something like check an IV before administering a med most of the time, then for safety's sake, it might be wise to make it a habit to do it every time. That's a hospital applying the "every time" of your posting. They are being careful.

Remember, the times when you're most likely to make a serious mistakeâ€”when you're harried and overworkedâ€”is also when you're most likely to skip the check that'd spot that mistake. It is the two together can be deadly. That is what you need to avoid.

mgturtle · Jun 23, 2015

Thanks for the replies. I should clarify that I am over Quality and it is very possible for a very good nurse to truly believe they know into what line they are administering a medication and make a mistake. So, I am not asking if it is a good idea or a basic expectation of a nurse. I know those things. I am asking does your hospital educate to this principal and hold nurses accountable to this practice meaning it is an expectation that every nurse does it every time? Thanks again for your help

AJJKRN · Jun 23, 2015

Thanks for the replies. I should clarify that I am over Quality and it is very possible for a very good nurse to truly believe they know into what line they are administering a medication and make a mistake. So, I am not asking if it is a good idea or a basic expectation of a nurse. I know those things. I am asking does your hospital educate to this principal and hold nurses accountable to this practice meaning it is an expectation that every nurse does it every time? Thanks again for your help

Nope, I don't believe it's touched upon during a new nurses orientation at my hospital. I do believe it is in our IV maintenance protocol that can be clearly missed if one does not do their due diligence to read the hospital protocols, which is why I answered the way I did...that it is expected we know :yes: . My hospital does hold us accountable but we do (thankfully) operate under a "no discipline" general rule for found errors so that workers are not afraid to do the occurrence report on incidents that will help find system errors and/or lack of education in the first place. I think the biggest barrier to this happens to be very sporadic orientations where a nurse (new or experienced) are not shown how to properly utilize the education resources available, like the entity's protocols, during orientation or after charting system upgrades.

MunoRN, RN · Jun 23, 2015

Tracing lines when you take over care of a patient (either when coming on shift or when a patient returns from procedure, OR, care of another nurse etc. I've never heard anyone advocate for tracing the line with each individual push after you've initially established that the lines are correctly labelled at the patient end, I don't really see how that would be necessary. Many nurses will often label their "push" port" specifically.

ChipNurse · Jun 24, 2015

Thanks for the replies. I should clarify that I am over Quality and it is very possible for a very good nurse to truly believe they know into what line they are administering a medication and make a mistake. So, I am not asking if it is a good idea or a basic expectation of a nurse. I know those things. I am asking does your hospital educate to this principal and hold nurses accountable to this practice meaning it is an expectation that every nurse does it every time? Thanks again for your help

If a policy isn't in place to check and label IV tubings, then maybe you can work to get a policy in writing. It would be hard to verify that nurses are tracing lines, but maybe create an auditing system for checking that IV bags and tubings are labeled appropriately (with label of med closest to patient). We also use those alcohol impregnated caps on our IV lines, but ONLY on lines that have maintenance fluid (NS, LR, etc) and capped lines. This is a good visual as to where nurses can push the intermittent drugs through.

SierraBravo · Jun 24, 2015

I was a nurse tech on a pediatric Hem-Onc unit, where our patients typically had complex, multi-pump, multi-bag IVs. Whenever possible, I checked every detail of the IV from the bag to the patient at every opportunity, generally every time I entered a room on night shift. It's all too easy to make mistakes in a dark room, particularly for a nurse that's handling up to seven patients who all have complex IVs.
There was a reason for that precaution. We were one of the first hospitals in the country to adopt the Hickman line for pediatric oncology patients and at the time we were having serious problems with air embolisms in those lines. I wasn't giving the meds. The nurse I worked with did that. In addition to my other duties was looking for any mistake that could lead to an air embolism, given the complex choreography of chemotherapy and its aftermath (blood products, antibiotics, and some anti-virals). Unfortunately, the air sensors on our IV pumps were separate from the pump itself, so the pump could be putting air into a patient while the sensor sat as silent as death on an unused line. You can read the details about how such errors can occur in the fourth chapter a book that's posted for reading here:
https://indd.adobe.com/view/c1892142-ecf8-4621-a7a9-eee8f0ce19ab
For me, the most important "when" rule comes afterward, at least for medications given by pump. When you've made any change to an IV, then, before you even think of leaving the patient, trace the entire path from bag to patient, checking every detail. It's changes made wrongly that will get you into trouble. That is either things you should have done but didn't or did do but shouldn't.
Situations can vary from hospital to hospital and patient to patient, so I'd suggest thinking through what you're doing in each of your treatments and spotting every potential error. Where you need to be particularly careful, are situations where those errors can be made.
If you read that chapter four above, you'd discover our situation. Yes, the mistake that caused an air embolism seemed unlikely. It only happened when several mistakes were made at the same time. But those mistakes were ones of omission not commission. In a hurry, it is easy to forget to do several steps than it is to do all of them wrong. In some 26 months at that hospital, I caught four embolisms, so they certainly weren't rare.
I've often thought that hospitals should have the equivalent of the bright-colored "Remove Before Flight" tags on aircraft. When a nurse makes changes to an IV, she's taught to flip a tag so a bright yellow "Check IV" shows. She doesn't leave the room until she has checked the entire IV path. Only then does she flip the card over to a green side that says "IV OK."
One more suggestion. Well-established habits make it easier to get something right all the time. If you need to do something like check an IV before administering a med most of the time, then for safety's sake, it might be wise to make it a habit to do it every time. That's a hospital applying the "every time" of your posting. They are being careful.
Remember, the times when you're most likely to make a serious mistakeâ€”when you're harried and overworkedâ€”is also when you're most likely to skip the check that'd spot that mistake. It is the two together can be deadly. That is what you need to avoid.

From a systems perspective, it's a surprise that you haven't had more unintended effects by using those pumps. I don't know what type of pump your hospital uses, but at first glance it sounds like there are way too many moving parts to keep track of. This sets even the most experienced nurses up for failure.