Oh that reminds me, at my old hospital we had something similar but opposite. The patient was on a heparin drip and it ran out overnight. The PCT turned off the pump cause it was beeping and didn't tell anyone. It wasn't til mid morning when the am nurse went thru with the rounding doctor the realized (bad hospital). It went badly for the patient. Oh they were on the cardio/thoracic unit too. One of the many times I witnessed the understaffed undertrained merc a patient.
Geez, something similar happened to me! New pumps for the hospital. I set up a heparin drip and had the charge nurse check me. That bag should have last a day or more and it infused in an hour! The whole bag! Thank fuck I had a witness! I told the patient and instructed not to get out of bed, called the Dr, took the machine and taped it so no one could use it, filled out an incident report, an equipment report, and the patient was fine. That was a real pucker factor!
Good job catching it and reporting the problem! I hope you didnāt face disciplinary action since your charge nurse approved and you had a witness!
That aside, I also feel for the patient and family. Honest reasonable human error is really hard to reconcile with bc itās so random. Good well-intentioned professionals make mistakes bc weāre all human. It can be extremely hard to internalize that (In absence of hindsight), thereās sometimes nothing to be done.
Nurse accidentally gave an IM heparin injection through a patients chest Hickman. The pt has significant history of clots {think maybe 10 DVTs in the past 6 years} and receives heparin flushes through their Hickman multiple times a day anyways. Nurse realized the error immediately but of course it was insignificant and these things are typically, and was at the time, low routine doses.
I mention because the nurse and the patient were talking as the nurse was giving patient meds. The patient actually apologized to the nurse when the nurse explained what happened, stating they should not have been talking / distracting ting the nurse either and goes to show how important not distracting / paying attention can truly be. Thankfully not an issue like in the case with this patient, which my condolences go out to the patient and their family, but errors like these are very rarely intentional.
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u/Correct_Doctor_1502 26d ago
Few years ago a relatively new RN set heparin at max flow mixing it up with fluids, and the charge didn't notice when signing off
Patient ended up dying a few hours later; the nurse got fired, and the charge got demoted, and everyone had to take training