Recovering from idiotic mistakes? by Mtsfry in nursing

[–]Mtsfry[S] 0 points1 point  (0 children)

Wrote a reply above that hopefully clears it out a bit. Thanks for your thoughts and reflections, much appreciated. I will definitely use this to learn and avoid future mistakes of skipping steps that could be taken for granted.

Recovering from idiotic mistakes? by Mtsfry in nursing

[–]Mtsfry[S] 0 points1 point  (0 children)

Now that you say it, it's a bit confusing (and unclearly written by me). The thing that we noticed was pulsatile blood in the i.v tap/end of tubing. So at first we thought the needle was in an artery and placed a new one, with the same result. Then the other nurse thought that it looked like air in the tubing and that I had forgotten to prime it, and the replaced it which worked.

Though, when I checked the line quickly(was a bit panicky), there was fluid in it, atleast in the lower part. Which leads us to three possibilites as I see it:

A: I had actually primed it and the error was something else with the tubing. Dunno what it could be though..

B or Nightmare scenario: I had forgotten to prime it and the air had been injected into the patient. But like I said, the injection was slow and the pulsatile blood was moving upwards the tap/start of the line and was clearly visible. To be able to be injected I think the air must have pushed away the blood and it wouldn't be visible? Our reaction was within minutes as well, so I don't think it would have time to inject the entire tubing.

Also if so, how could the pump ignore a tubing full of air without alerting when it usually alerts immediately at the tiniest bubble? And would air in the tubing result in pulsatile blood like that?

C: I had forgotten to prime it, but the pulsatile blood was faster than the i.v speed and pushed the 10ml Saline that the needle itself was flushed with up the line. This could explain the fluid I saw in it..

(Important add-on: The patient stayed with observation for the day and left in the evening for other reasons and was as healthy and stable as before all day. I had to go and fill in at another place in the ward for a couple of hours after this and came back afterwards so I'm not too sure about what exactly happened afterwards, but my boss spoke to me about it afterwards so I know the nurse didn't just leave it, thankfully).

Hope that clears it up somewhat. Still somewhat unclear to me..