A charge nurse needed to provide saline solution for her patients without the assistance of IV pumps that were necessary to measure the mixture. She measured by hand, eyeing the amount in the IV with a flashlight. A nurse on the next shift discovered the wrong medication was provided to the patients. The patients were dead within two weeks.
An investigation revealed the lack of training received by the charge nurse. “The nursing supervisor said that she had not received any IV training from the facility,” the Department of Public Health report states. “The nursing supervisor said she had not used the IV dial flow regulators in years and said that on [the … night shift] there was no IV pump available to accurately monitor the fluid volume in the facility.” For more, read the story.
