Would YOU have reported it?

[Annie Wilkes RN]

My patient had 1/2 normal saline running at 100 ml/hour when I assessed him after shift report. The physician came in and ordered to discontinue the normal saline and start D5W at 50 ml/hour. Indeed, he had ordered normal saline yesterday. I took down the 1/2 normal saline, hung the D5W at 50/hour and moved on. I did not tell anyone. I'm considering pulling that nurse aside and letting her know so she may be more careful in the future, as our pyxis system sucks and is easy to make such an error if one is not careful. My patient's condition was stable for my shift. Should I have reported this? I don't want anyone to get in trouble. I know if it had been something dangerous, I would have reported it...but this?

We all make mistakes, right?

[heronurse]

Ohhhhhh sorry not yet familiar with IV's i thought 1/2 normal saline is 500cc normal saline hahah my bad

[CBlover, BSN, RN]

Yea. Ok. When I read it, I didn't see the two salines. I thought she was saying that nurse "A" had 1/2 normal hanging when the doctor had written an order to change to D5W during nurse As shift. And when nurse B came on, she noticed it had not been changed to D5W.

[TXJDRN]

Echoing what others have said here - the medication error must be reported. That you have second thoughts because you don't want anyone to get into trouble is troubling to me. In the first place, if this is the nurse's first mistake then she will be reeducated on the different types of IV fluids and what each is used for. Or, she can take it upon herself to learn more about each type of fluid. But saying nothing should not be an option and if it still an option you considered, then I recommend you do some reflecting about your moral compass and ethical values.

[litbitblack, ASN, RN]

I understood 1/2 ns was hanging but the day before the order was changed to NS. The new order changing what should have been Ns was changed to D5 NS. Yes it should be reported. It sounds like a system error and something that can be easily prevented. The only way errors are prevented is to look at the process and investigate.

[cayenne06, MSN, CNM]

I agree that this warrants an incident report, but I too would be hesitant if I was concerned about the repercussions for my coworker. However, she deserves to be made aware of the mistake so she can improve her practice, because this is clearly a medication error that had potential for harm. And the facility should be made aware so they can take a look at their dispensing system. Maybe they shouldn't have multiple types of IVF, all almost identical to a passing glance, sharing the same pyxis drawer or shelf space.

I never understood why the damn bags weren't color coded with big stickers or something.

Yes, proper med admin is our responsibility, full stop. But human error is easier to avoid if your system is built with that in mind. And administrative response to mistakes should focus on the actual goal- patient safety and employee well being. And not to mention a bit of kindness and grace for the caregiver who made the mistake. Glass houses, right?

It really grinds my gears that in so many facilities, nurses are conditioned to be hesitant about reporting mistakes due to fear of punitive action. We are human, and we are absolutely going to make mistakes. Because of the nature of our work, sometimes our mistakes can cause harm to a patient, or even kill them. Therefore, it is critically important that providers feel comfortable reporting errors, whether benign or harmful. That is how we identify problems and (hopefully) improve our systems and protocols to make errors less likely.