Melody

I am an RN...what she is doing is totally WRONG!!!! He can get septic from that..it is likely contaminated. I want you to call the nursing agency immediately and your physician as well.

I can't belive some RN would be that stupid. I am sorry to be so blunt but that is like using a dirty needle, even worse.

I am so mad!!!

Mel

That bag was contaminated the second that it got a hole in it...that moment. Whatever caused the hole penetrated into the sterile fluid in that bag....it could be anything, and no antibodies in IVIG won't kill it....

She simply transferred contaminated IVIG, into a sterile bag, using sterile equipment...but that is no help...the contaminant is already in the fluid.

Alan will likely be OK, but this is horrible practice!! On the other hand, he could have staph or strep or e.coli or God knows what, in that bag...whatever was in the frig, or pharmacy, or vehicle, that the IV bag was sitting in before the leak was discovered....whatever was on her hands when she handled the bag. If you have the IV bag that leaked keep it. It could be what you need to track down a germ if Alan does get an infection. Septicemia is very dangerous.

This is utterly unacceptable. No nurse in her right mind would do this, no matter how nice she is, she risked a patient's life. I am even more peaved.

I did home care nursing for years, and this just blows my mind!!

IVIG is very expensive, however it is not worth saving costs over a patien'ts life...ever! I can not tell you how angry I am!!!

Mel

I am still seething. Sterile procedure is one of the FIRST things nurses are taught. It is repeated over and over again thru out your education....then when you are hired, they go over it again...every nursing agency has a procedure and policy written regarding this...this is so elementary, it makes me wonder if your nurse is really a nurse. You are usually required by your employer to demonstrate sterile technique every year in a skills test.

This could not only cost her, and should cost her her nursing license, or at least her job. Her judgment is so poor, she needs to start all over...step 1 of training.

This could cost your home care provider their license or certification, certainly if the state or joint accreditation heard about this they would immediately discipline or fine the agency. It is THAT serious of a screw up.

Feel free to PM me for more info. For all of you....do not let any one ever stick a thing into you that is not sterile....no double picks with a needle....no leaking IV bags or tubes....Even a leaking tube requries dumping the bag, as stuff can travel upstream. Think of how many germs live on the head of a pin...

You should call the nursing agency's oncall number and you tell them what happened now...it needs to be written up....and you need a new nurse. I am sorry you are emotionally bonded with this person, and that is tough, but this action is so incredibly professionally obscene I won't sleep all night!!

Mel, you and Alan are the nicest people. This kind of stuff should not happen to you....It should not happen to any one. This is malpractice.

Wow, I had no idea.

Alan just went to bed and thankfully, he seems fine.
I watched her do everything. She used sterile gloves. Everything she opened was sealed up and while I don't know about the leaky thing, she did indicate that it had to have come from the pharmacy's end.

Actually, Alan thinks she might have accidentally done it when she hung the bag over the iv pole. As I think about it, I took the bag out of the fridge one hour before she came and hung it on the iv pole. So it was not leaking.

When she took out the sterile tubing and attached it to the bag, she was doing stuff so fast I can't even begin to tell you. When she took the long tubing and inserted it into the Gamma bag, she said: "uh oh, there's a leak, let's see if we can stop it, do you have any tape?" I immediately got the some strong sterile tape that I use on Alan bandages (I never put this tape on his skin, it's too strong, but it's got a good adhesive to it, but, unfortunately, the tape didn't do what we hoped it would. That's when she got the idea of getting the bag of saline from her car.

I know for a fact that I took the Gamma Bag out of my fridge and hung it on the iv pole. There was nothing leaking, so there was no contamination.

Want to know what I think? I think she poked a tiny hole in the botton when she tried to screw in the tubing. I saw her pushing and screwing the tube in and she was having a hard time. I think she did it and didn't want us to know.

But when she transferred the gamma, she really did everything wearing gloves and opening up new tubing, etc.

And nothing touched the air, I watched her the whole time.

And, you will be happy over this......the girl we had yesterday, her name is Magalee, she will be our permanent visiting nurse. We arranged this yesterday.

So I think Alan is okay. Hopefully.


AND IF THE BAG WAS NOT LEAKING AFTER I HUNG IT ON THE POLE (BEFORE SHE ARRIVED), IT HAD TO BE SOMETHING SHE DID, RIGHT?

AND THERE'S NO OTHER BAG IN THE FRIDGE. Today was the second infusion. Next month we do it again.
Melody

P.S. When she saw that the bag was already mixed, she commented, "oh, it's mixed already, I have never done an ivig where I didn't have to mix it first", I replied, "yeah, everybody says that, but we have never had to mix anything, it comes already mixed".

I just took the Gamma Bag (the one with the leak), out of the plastic bag. I took two photos.

Look at the left part of the picture, (that's where she tried to hook up the tubing), see if you can see how this leak COULD HAVE HAPPENED!!!

Oh, just to be clear, when she was about to do the transfer, I asked her, "can't you just tear a little hole in the top of the gamma bag and pour it directly into the other bag"? and she said "Oh my god, no, I can't do that, this has to be a sterile environment".

and you gimme Pictures?! KEEP THAT BAG...That's nurse error...re-training required?
Believe me, I can SEE that 'poke' for better way of putting it? Put that leftover bag in a double-bag set of zip-lock bags and tote it to Dr Fred or the neuro ASAP. [putting it in the fridge-just to keep other new junk from accumulating wouldn't hurt] YOUR docs have to SEE the bag. no ands ifs or buts.
I am glad Alan is fine so far, is he getting more tomorrow? Call if you can your doc[s] tomorrow AM and just ask IS THIS NORMAL? I am not gonna bet here, cause I know it isn't. Any headaches, rashes, nausea, or heart-racing feelings, even strange breathing feelings....you call rite away, Promise.
Yes. This as I've said before IS serious stuff. It may be that your next nurse is going to be different. YOU need to think not HOW NICE THE NURSE IS...YOU NEED TO THINK of HOW SAFELY THE NURSE IS ADMINISTERING IVIG to your precious ALAN! Professional-following safety precautions=SAFE, Nice is JUST a bonus! Trust me on this!
Having gotten a bad infusion [at a hospital no less] I 'think' I do know the difference...that bad infusion could have killed me-the hospital nurses got -re-trained as a result of my complaints - they kept telling me after that 'they'd admitted 2 this mo w/reactions, next time 3 this mo w/reactions-so I guess my grumps did some good [also a rebate on some tossed IVIG {I did cry seeing such precious stuff go into the bin?}. So I am still here to give you my advice of caution. Upon reflections, I don't think I can agree if I break out in sweats or get overall chills and goosebumps at the thought? None of us ever want to GO THERE IF WE CAN HELP IT!

When ya crawl inta bed, just sorta give ALAN a half-hug from me? That he's OK is the most important thing!

Alan is going to Dr. Fred's tomorrow morning. Dr. Fred is not there, just Frank the paramedic who takes everybody's blood. Should Alan take the bags (I zip locked them each in separate zip lock bags).

I can write a note explaining what happened.

Now I know my husband. If he is feeling fine, HE'S NOT GOING TO WANT TO BRING THIS TO DR. FRED'S OFFICE. I know Alan. He just won't.

I'll just have to make this a wait and see thing.

Right now, they are both sealed up and in my fridge.

I am NOT GOING TO SLEEP MUCH TONIGHT. Not after all this scary stuff.
Melody

in 97% of whatevers, NOTHING happens, I just got lucky -therefore gun shy?
But, by keeping that stuff and showing it to Frank, I'll bet cha dollars to do-nuts that HE will go WHAT? or the like...maybe not even say it out loud, but the eyes WILL widen or narrow ...I do believe that. The note of what happened is good as well. That way, YOU will have a record of what happened from your viewpoint and the pics! GOOD there!

I simply wanted to warn you that at times really bad stuff can happen, no matter how well informed we try to be. Its not usually anyone's fault, just that they're not trained or up-to-date on the rite procedures and all. It can be scary--you just have to know when to say NO WAY! This is not right!

I truly don't want the 'odds' to catch up to Alan with his conditions in a way that hurts HIM and YOU.
That then MAKES YOU the one who has to be the Watchdog, so to speak. I know you can be, and are that 'watcher'...but often there are more 'things' to it all than you have thought. There are. I will be more than glad to help you. BUT I have to warn you....it is information YOU will have to memorize for the 'just in case' scenes...not needed now...just in the 'memory bank' so should problems come up...IT's there in your 'recall memory bank'! It can avoid soo much hassle in the long run?

- truly - j

here that our concerns are real...IVIG IS a blood product, and the LAWS and PROCEDURES for handling blood products are VERY STRICT.

Please pay special attention to pages 11 & 12 in the following site.

http://www.primaryimmune.org/pubs/nurse_guide_igiv.pdf

While what the nurse did was 'expedient' -a way to get it done, I really think you should call the source of the IVIG and just ask questions....explaining all that happened -in set up and in infusion. It mite not be the nurse's fault, merely that she's not had up to date training on what a Nurse CAN AND CAN't DO. So many other factors come into play, we won't play with them, OK?
Promise me, that you will call your prescribing doc, the neuro right? And, just ask IS THIS THE WAY IT SHOULD BE DONE? You check that other bag of IVIG in your refrig, now please, and IF IT too is leaking. YOU CALL THE COMPANY/SERVICE NOW [they have pharmacists on call 24/7] and someone will call you back ASAP. REFUSE NOW that bag being put into ALAN! I trust others here, I believe I did receive a contaminated bag/batch [AT a hospital, no less?]. ALAN's life is too precious to you, and thus, to us...to trust in possible human error. Stuff, does happen. This kind of thing, with all the regs on IVIG, shouldn't.

Please, call your doc, and the IVIG supplier, who is it? Gammagard, Gammunex? Whoever...I can get to you the web-sites and 800 #'s in a flash, just tell me which who? The manufacturers really DO want their products into any patient in the safest, fastest [as safe] and most professional way! I've dealt with these guys, and really once you get them - they can be really really good sources of support!

I hope we all hear from you soon, usually if anything icky happens, it's in the first 2-3 days after an infusion...could be the first or the second.

I don't want you to panic, I just want you to be SURE you know what you REALLY need to know about getting it safely!

's to you both! - j