Well-established habits make it easier to get something right all the time. Only then does she flip the card over to a green side that says "IV OK." She doesn't leave the room until she has checked the entire IV path. When a nurse makes changes to an IV, she's taught to flip a tag so a bright yellow "Check IV" shows. I've often thought that hospitals should have the equivalent of the bright-colored "Remove Before Flight" tags on aircraft. In some 26 months at that hospital, I caught four embolisms, so they certainly weren't rare. In a hurry, it is easy to forget to do several steps than it is to do all of them wrong.
But those mistakes were ones of omission not commission. It only happened when several mistakes were made at the same time. Yes, the mistake that caused an air embolism seemed unlikely. If you read that chapter four above, you'd discover our situation. Where you need to be particularly careful, are situations where those errors can be made. Situations can vary from hospital to hospital and patient to patient, so I'd suggest thinking through what you're doing in each of your treatments and spotting every potential error. That is either things you should have done but didn't or did do but shouldn't. It's changes made wrongly that will get you into trouble. When you've made any change to an IV, then, before you even think of leaving the patient, trace the entire path from bag to patient, checking every detail. You can read the details about how such errors can occur in the fourth chapter a book that's posted for reading here:įor me, the most important "when" rule comes afterward, at least for medications given by pump. Unfortunately, the air sensors on our IV pumps were separate from the pump itself, so the pump could be putting air into a patient while the sensor sat as silent as death on an unused line. In addition to my other duties was looking for any mistake that could lead to an air embolism, given the complex choreography of chemotherapy and its aftermath (blood products, antibiotics, and some anti-virals). We were one of the first hospitals in the country to adopt the Hickman line for pediatric oncology patients and at the time we were having serious problems with air embolisms in those lines. It's all too easy to make mistakes in a dark room, particularly for a nurse that's handling up to seven patients who all have complex IVs. Whenever possible, I checked every detail of the IV from the bag to the patient at every opportunity, generally every time I entered a room on night shift. Of course, that said, I would not argue with you about the value of color coding schemes in anesthesia where the system is used as intended.I was a nurse tech on a pediatric Hem-Onc unit, where our patients typically had complex, multi-pump, multi-bag IVs. Also, it's been my observation that these labels often are used without recording the amount of drug contained within (I've seen this many times on our hospital visits to the OR). Therefore, anyone other than the person who prepared the syringe may be in danger of using the wrong drug if they rely on color without reading the label. Although when properly applied the color of the label identifies a drug category, the scheme does not necessarily identify a specific drug. We've also observed occasional problems with user-applied color coded labels in anesthesia. We've had quite a few tenfold overdoses of insulin because the 26G needle on some tuberculin syringes is now orange (recent change), as is the color assigned to insulin syringes. Another example is color coding of disposable syringes by needle gauge. The ophthalmologists love the system but pharmacists and nurses, especially those who've made dispensing errors, hate it.
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