We all learn from our mistakes

[AussieKylie]

Yesterday we didnt have any gel packs to assist with patients back pain from his post operative surgery 4 days ago. We had Acute Pain Service team come around to assess this patient and they suggested a heat pack. Because we ran out of the gel packs to heat up in hot water, I improvised and got a plastic bag, put a towel in it, put hot water in the plastic bag over the towel then wrapped up the plastic bag with another towel and put it in a pillow slip. Took it back and one of the nurses suggested I get an IV Bag and heat it up in the microwave. Instinctively I didnt like that idea due to the fact we dont put gel packs in Microwave so why put an IV Bag. So I thought well if it works for her I better do it, being that she has more experience than me and I am only a Grad RN. She suggested I heat up the IV Bag for 2 minutes, and I am thinking no way. I only put it in for one minute checking every 50 seconds. This IVBag assisted the patients pain. However during the end of the day, our physiotherapist caught on to the idea of the so called heat pack being used (IVBag) is bad practice (in which I agree too). I told him the story about what happened and even the patient backed me up on it. I know the potential is there for 3rd degree burns if ever the IVBag ruptured. However I just didnt know any better and thinking that if an experienced nurse has had the use of IVBags as heat packs then maybe it could be okay, even though instinctively I thought errrrrrrrr ummmmm I dont feel ok with this.

So the physiotherapist wanted to know who it was from the Acute Pain Service team that advised this then it was reported to the Nurse Manager and I filled out an Incident Report.

In the end I have learnt two things:

1. Not to use IV bags as heat packs in microwave

2. Trust your instincts and say No to that person that suggests such unsafe practices

:uhoh21:

[GeminiTwinRN, BSN]

does your facility have those warmers where they warm up shower caps (the ones with the "built in shampoo" that need no rinse)? i worked in a facility that had those, and we used them all the time for heat packs. they worked GREAT!

course, now i work in a level 1 trauma center (teaching hospital) where the budget is extremely low (read CHEAP) and there are no such luxuries here..

just a thought.

:)