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Health and Disability Commissioner responsible for counting the drip rate on a regular basis and changing it to the required rate so that the correct amount of fluid was delivered to [Miss C]. • [Miss C] was received in Recovery by [Ms G] who states in her letter to the Commissioner that she monitored [Miss C] and manually adjusted the drip rate to ensure it was running at the prescribed rate. As [Mr O’s] letter to the Commissioner states that the ward nurse who received [Miss C] from Recovery estimated that approximately 200mls had been administered in theatre and recovery, it is my opinion that [Ms G] monitored [Miss C] and the drip in a manner that met professional standards of practice. It is often necessary during an operation to administer fluid at flexible rates to maintain blood pressure and to administer drugs and as only 200mls had been used it would seem that for the hour [Miss C] was in recovery she was administered the appropriate amount of fluid. • [Miss C] was returned to the ward at 11.30am approximately and responsibility for her care was taken by Ms I who notes in her letter to the Commissioner that she did not check the drop rate as ‘… I assumed it to have been set in recovery …’. Managing intravenous infusions (drips/drops) at the prescribed rate is a nursing responsibility and because many factors can affect the flow rate, the drip does not necessarily continue to run at the rate originally set. The nurse must therefore monitor drips frequently (15-30 minute intervals) to ensure that the fluid is running at the intended rate (Brunner and Suddarth). In my opinion [Ms I] did not exercise reasonable skill or care in the monitoring and regulation of [Miss C’s] drip and therefore did not meet NZ Nursing Council standards in relation to performing [Miss C’s] care in a way that was safe (NZ Nursing Council, 1999, 4.5, 4.6, 4.7, 4.8). • When the afternoon shift commenced at 1445 hrs, [Ms K] assumed responsibility for [Miss C’s] care. [Ms K] notes in her letter to the Commissioner that she commenced the third litre of fluid at 1745 hrs. This meant that [Miss C] had received 2 litres of fluid over seven and a half hours approximately when [Dr E] had instructed the nurses that [Miss C] was to receive 80mls of fluid an hour. [Ms K] notes, ‘… that it was not obvious to me that this was the third bag of fluid … I also failed to chart it on the fluid balance chart’. It is my opinion therefore that [Ms K] did not exercise reasonable skill or care in the monitoring and regulation of [Miss C’s] drip and therefore did not meet Nursing Council’s standards of ensuring effective and safe nursing care for [Miss C] (NZ Nursing Council, 1999, 4.5, 4.6, 4.7, 4.8). • [Mrs M] took over [Miss C’s] care at 1745-1800hrs and provided one on one nursing care. She noted that the drip was going fast so turned it down and requested an infusion pump. There was a delay in receiving this and by 2030hrs when the Cogentin infusion was ordered [Miss C] had received another 700mls (approximately) of fluid over 2hrs and 45 minutes. This means that over that time, [Miss C’s] drip was running at approximately 250mls per hour. It is my opinion therefore that [Mrs M] did not exercise reasonable skill or care in monitoring and regulating [Miss C’s] drip and therefore did not meet Nursing Council’s standards of 14 18 June 2002 Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name.
Opinion/00HDC00231 ensuring effective and safe nursing care for [Miss C] (NZ Nursing Council, 1999, 4.5, 4.6, 4.7, 4.8). Regulation of Drips • Drips work by gravity flow and the rate of flow may be regulated by clamps on the tubing which are tightened or loosened to adjust the flow rate or by infusion pumps which are designed to provide constant but adjustable flow of solutions given intravenously. Pumps usually work by applying intermittent pressure on the drip tubing and provide more accurate administration of fluids and medications than is possible with gravity flow set-ups. The use of calibrated burettes can help ensure that the prescribed hourly amount of fluid is administered. Burettes are filled with the amount of fluid to be given each hour and set at the appropriate drip rate. This requires the nurse to fill the burette on an hourly basis and therefore decreases the likelihood of administering too much fluid. [Miss C’s] drip was a continuous gravity flow with an adjustable clamp on the tubing. Because of the difficulty of maintaining the flow at a constant rate with this type of set-up, it is my opinion that [Miss C] needed either a burette or pump or both. I note on Page 2, no 2 of the [private hospital’s] Intravenous Policy in operation at the time of [Miss C’s] surgery, that ‘children < 10 years to have Burette or Floguard’. It is my opinion therefore that the nurses caring for [Miss C] did not meet professional standards of practice. This particularly applies to the ward staff who cared for [Miss C] as she was restless and vomiting and this increases the likelihood of the drip rate varying. According to NZ Nursing Council (1999, 6.6) nurses are required to administer interventions, treatments and medications within legislation, codes, … and according to authorised prescription, established policy and guidelines. Importance of Flow Rates • Flow rates determine the amount of fluid delivered to the patient and it is therefore a critical component of patient safety that the flow rate is accurate. Flow rates are calculated in drops per minute and the nurse who is caring for the patient is responsible for ensuring the accuracy of the flow rate. With the continuous flow setup of [Miss C’s] drip it would be possible for an entire litre of fluid to run through very rapidly so it was extremely important that her drip was monitored at 15-30 minute intervals and that the inline burette or infusion pump was used to decrease the likelihood of administering too much fluid. The use of burettes and infusion pumps is not a guarantee of safety and when these are used they also require monitoring on an hourly basis at least (Brunner & Suddarth, 2000; Ashwill & Drosk, 1997). Factors such as movement, position of the limbs and of the patient can all affect the flow rate of a drip and as [Miss C] was fitting in the evening this could affect the flow rate also. It is my opinion that the nurses should have been checking the flow rate on a regular and frequent basis as described above and should have also checked and reset the flow rate at the times the bags of fluid were changed. 18 June 2002 15 Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name.
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