Published Jul 21, 2006
Irishgirl
88 Posts
Okay, for anyone who has ever read my posts, it's no secret, I have OCD. It sucks. But for my piece of mind (and until my meds become therapeutic-I just started today) I need some words of wisdom. I had a situation at work where I unhooked an IV line that had a unit of blood going into it. The bag had a pressure bag around it, wasn't hooked into the pump, and was connected to the pt's IV (not my pt). I was asked by another nurse, for whom I started a new IV in the other arm, to switch the line over. I assumed (yes ass out of u-m-e) that it was clamped (b/c it was still hooked up to the bad IV, but that could have freed up and free-flowed PRBC's into the pt!) so I unhooked it and guess what? Yes, blood everywhere. I put my hand around the end of the line to keep the pt from getting an impromptu bath (maybe dumb, but the lady was happy). I wasn't even working on that unit that day, I was just passing by and was asked to do a favor, to which I agreed (also dumb). I told the other nurse that I contaminated the line, so it needed new tubing. My fear is, in trying to save blood she may have tried to back the blood in the tubing back into the bag. But, she's a great nurse, so hopefully she just changed out the tubing and cut the loss. I wouldn't want contaminated blood from the end of the tubing to back up into the bag and make the pt septic. Can it even back up with a blood filter on it? What are the chances of sepsis here if she did back it up? Is this crazy? Be honest...
CritterLover, BSN, RN
929 Posts
well, i suppose that telling you that it was her patient, you were trying to help, and that you need to let it go isn't going to help, right?
i don't believe that blood filters, in and of themselves, prevent reflux. i think you need to have an anti-reflux valve for that. unfortunatly, i would venture to guess that most blood tubing sets do not have this feature, as i often see nurses back-priming ns into blood through the admin set to thin it out some. this wouldn't be possible if there was an anti-reflux valve on it.
that being said, do you really think it is possible that this nurse would put the patient at risk for sepsis over the few cc's of blood that were in the tubing?
funny, a similar thing happened to me a few weeks ago. had a trauma (gsw chest) patient come in. as we were trying to fly the patient out to a trauma center, we had 2 units of blood running on the same pressure bag (though different sets of tubing; could only find one pressure bag). one finished, the other was still running. i thought i had traced the empty bag down the line and was going to disconnect/flush the line, but removed the wrong set of tubing. immediate blood bath for the patient and the flight nurse that was standing next to him. :imbar . it happens.
Would it be my fault if this lady became septic? I did tell the nurse that it was contaminated & I saw her changing the tubing over, I just didn't see if she re-primed the blood or back-primed it. She didn't even want me to help her clean up...I'm torturing myself over it, thinking if this lady became septic it would be on my hands & that makes me a bad person, undeserving of the good things I have...crazy? Probably, but is it true?