I hung the wrong fluid with blood-please help
This topic contains 23 replies, has 11 voices, and was last updated by Marilyn Sigler 4 months, 3 weeks ago.
April 19, 2017 at 2:33 pm #71546
A couple of days ago I made the mistake of hanging the wrong fluid with blood during my shift a couple of days ago. The nurse manager called me last night when I was eating dinner. to tell me that I had made this error.
I realize that blood should only ever be hung with NS but I hung it with D5 1/2 NS The manager told me that she would discuss it with me sometime this week and I’m freaking out. I can’t believe I made such a dumb mistake by doing this. I definitely know better and I am scared I’m gonna be in big trouble over this. Any advice is appreciated regarding this issue.
They caught the mistake within an hour while I was on break and another nurse reported it to the manager.
April 19, 2017 at 2:37 pm #71547
This is very serious. Hanging the wrong fluid with blood can potentially be fatal to the patient. Since they caught it relatively quickly then you are very lucky. Is the patient okay? or do you know?
Why did this happen? Did you just not check it? Where you too busy? All of these questions need to be answered and be prepared to answer them when you meet with your manager.
This is considered a medication error and will be investigated. You must make sure you check and double check everything before giving it to a patient. I hope everything will be okay for you. Keep us posted
April 19, 2017 at 2:46 pm #71548
That’s kind of a big deal. I am sure you were busy but that’s not an excuse to make these kinds of mistakes that can cost someone their life. You have to take your time, especially with dangerous IV fluids and medications, such at K, blood, Dig…etc.
Hanging glucose with blood can cause hemolysis of the cells by aggregation.
April 19, 2017 at 2:50 pm #71549
This is exactly why we have to keep fluids separated from each other in storage because you get in a hurry and grab something that you thing is just NS when indeed it’s D5 1/2 c NS. That’s frightening. We always keep them apart.
But you should have also had the other nurse that checked the blood with you check the way you are going to be infusing it as well, including the fluid that you intend to hang with it.
You certainly need to be more careful, although I’m sure you are aware of that by now. Sorry this happened to you.
April 19, 2017 at 2:58 pm #71550
Angela Browning RNParticipant
This is no joke as I’m confident you know. It could have killed the patient. You can’t add sugar to blood or you have syrup. That’s not something that needs to be floating around in your veins and arteries. Be thankful that it wasn’t straight Dextrose by itself. The fact that it wasn’t its probably why you have a patient who is still alive. Well, that plus it sounds like it was caught relatively quickly.
If clots formed they were probably caught by the filter before they went to the patient, thankfully. You will never make this mistake again, I’m sure.
April 19, 2017 at 3:06 pm #71552
The patient is ok thank God. I’m so thankfully someone saw the mistake and fixed it. I just don’t know what is going to happen now. I’m sure I’ll get a write-up but I hope it’s nothing more than that. I realize how serious this was and the nurse that checked it off with me didn’t check the fluid, I don’t think. Wouldn’t that make her just as liable as me?
April 19, 2017 at 3:18 pm #71553
I can’t stress to you how dangerous this is. You don’t know how lucky you are with this. It’s a major league screw up. I’m not trying to scare you but you may even lose your job, or right to practice nursing over this one. Just telling it like it is. I’m sorry if that scares you, but it’s the truth. Sugar and blood don’t mix at all.
April 19, 2017 at 3:38 pm #71556
I get the impression that you haven’t hung blood a lot. In the beginning always ask or say I have this I am going to do this. You could loose your job. I hope you don’t but it is possible. Two nurses are suppose to be apart of this process.
April 19, 2017 at 4:05 pm #71561
I don’t know the laws everywhere else but in Arizona you have to have another RN sign off with you. Learn from your mistakes and embrace it. It’s the only way we improve ourselves. Talk to other nurses about their mistakes as well and ask them what they did to prevent it from happening again. Always read out loud what you are hanging and if you question it check before you cause an error. Double check blood bands, check the labs in the computer, check your blood bag, check your tubing and always hang with NS. Do not be afraid to ask for help or advice.
April 19, 2017 at 5:26 pm #71563
You double check the blood, not the fluid, maybe that should be a new standard too?!
April 19, 2017 at 6:26 pm #71565
They do that everywhere but the other nurse would be focused on the blood not what was hanging with it.
April 19, 2017 at 6:26 pm #71566
When I double check, I check it all. I think we need to get into the habit of doing so. A mistake can happen to anyone and if we can help prevent it then we should. I know we only sign off on the blood but why not take the extra second and do it all? Let’s all make it a goal to look out for one another.
April 19, 2017 at 7:26 pm #71569
In Australia (or Western Australia at least) we are trained to have everything we hang checked, so if you’re giving IVABx, whether a push or infusion, we have the actually antibiotic and the flush checked.
April 19, 2017 at 7:26 pm #71570
Patty Hagan Crowley
Mostly all places check with another RN and Re check like everyone said we learn by our mistakes.
April 19, 2017 at 8:26 pm #71573
Shelley Owens Patterson
Did anyone read the comments after the article. I really feel sorry for the RN. Some are telling her she might lose her job and even license over this.
The fact that the mistake was caught, she didn’t try to hide it or deny it, and there was no harm to the patient – she needs a learning lesson here. Not to lose her license or job. We all make mistakes. That’s no excuse. But we need to turn all of these into learning opportunities. Not punishment. We try too hard to chew up our newer nurses when we need to be mentoring them. Maybe change policy to have both RNs check blood and fluids.
April 19, 2017 at 8:27 pm #71575
I feel so bad for you. This is horrible. We are all human and we do make honest mistakes. I really hope you don’t lose your job or your license over this. I think the BON is supposed to investigate medication errors like this.
In our facility, you have to have two RN’s to check blood. But we do the five rights and check the blood type. The second RN isn’t really required to check the fluid, but this probably should be changed.
April 19, 2017 at 9:26 pm #71576
Yeah you do check the fluid! You check every fluid in Queensland, giving the wrong fluid to anyone without checking is dangerous. You should also be reading any information that came with the blood product and your facility policies and procedures. That’s what your signing each and every time you give a medication, that you gave it and you know your stuff!
April 19, 2017 at 10:26 pm #71578
Jay Q. Nichols
April 20, 2017 at 4:28 am #71580
Everyone makes mistakes, whether serious or not. I hope everything works out ok in the end. I suppose your manager being in no urgency to speak to you is a bit of a relief! 🙂
Personally the whole topic confuses me as a nurse working over in England. I assume elsewhere it’s common practice to put fluids up with bloods?
Basically we only use certain medications before the infusion- ie your fresh frozen plasma, platelets, furosemide (to prevent overloading patients) etc.
Very rarely we have bloods and fluids running at the same time as fluids dilute the blood down when the unit is finished. Our policy is to take bloods and if the HB is still low, then put up the second unit of blood and repeat HB half an hour/ an hour following that unit.
Take it as a learning curve. It’s all part of the experience of being a nurse. It happens. Just move on and carry on in your profession. 🙂
April 20, 2017 at 8:28 am #71581
This is why all parenteral solutions are double checked at the bedside
April 20, 2017 at 3:27 pm #71583
It is possible she could loose her job, but I hope she doesn’t. However you can kill someone if they have a reaction to the blood and it is your fault. Where I have worked we check so many things involving the blood to the point that are heads spin afterward. No one is perfect I agree but as a nurse you must understand the seriousness of the mistakes you make. Some can be swept under the carpet and some can’t. The NS is used to prime the the tubing and should be clamped off while the blood is running.
April 20, 2017 at 10:26 pm #71585
Jennifer Wood Baima
April 26, 2017 at 2:35 pm #71672
Gosh this is really scary. I really hope this works out for you and you don’t face disciplinary action by the hospital where you work, or the board of nursing. If anything, take it as a learning experience and don’t do it again. I suppose that goes without saying though!
May 1, 2017 at 2:26 pm #71717
When I hang blood the fluid doesn’t mix with the blood. Unless you use the fluid to prime the tubing. In that case the reaction would happen in the first 15 minutes which usually you are required to stay with the patient. Hope they just decided to educate you.
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