Troubleshooting and General tips
1. When I receive my TPN bags year round, I touch them to confirm they are cold enough and stay that way in refrigerator. Also during extreme weather conditions there are chances of delay of supplies delivery during transit, its a good idea to be in direct contact with home agency and have some kind of back up plan and I also keep some ice bricks handy for storing my bags in case of a power outage. My home agency is not in the same state where I live, so when I run into situations where I need spare bags I request them to send out some extra in advance or get it delivered by some near by home agency.
2. Avoid using expired bags and make sure fresh bags contain all ingredients from doctor's prescription, examine the bag carefully for anything unusual like leaks or cloudiness or floating particles. DO NOT keep the bag under direct sunlight, lamp or heat it up in a microwave. If needed, I run a towel in the dryer for 15 mins and then wrap it up around the bag or run some warm water over the bag to bring at room temperature.
3. Stat test - Sometimes blood reports can show drastic variation in levels and being on TPN, during these times patients are advised to get repeat testing done when there is emergency need. My doctor orders Stat test in such situations.
4. Stockinette medical - Sometimes, I use stockinette medical to secure my picc line and also keep the lumens from dangling while resting or doing any other activity. Regular stores carry cotton socks that can be used as well.
5. Blood draw - During the first year on TPN, I used to get blood work every week for some months and on biweekly basis/monthly thereafter. Now it's done every 8-10 weeks since my reports would come back normal, I requested my doctor to change the schedule and this also reduced the nursing visits. The blood work is done by Quest labs or Labcorp for me depending on coverage by insurance and the results are sent back to my home agency and I get a printed copy or email. I also prefer to replace the red cap soon after blood draw to avoid any bacterial growth, this protocol is followed by most people.
6. Shower sleeve - It is a huge challenge to take a shower with a PICC line. Shower sleeves are available and I tried a few but none of them worked for me. So I found this tip from Oley.org where it was recommended to use "Press n Seal". I have been doing that for 2 yrs with some additions and it has worked out well to keep my line dry after a shower. Press n Seal from Glad is available in all common food stores. It is a see through plastic wrap that sticks very well to the skin and this is a link, http://www.glad.com/food-storage/plastic-wrap/press-n-seal/ .
7. Tubing - When I was doing nighttime infusion, I used a single CADD tubing for a long time and I had no option but to hear the annoying sound that the pump made. We tried using travel bags to keep my bagpack but nothing really worked. Later after many trials, my agency sent microbore extension set so I could attach them and keep my bagpack in my room closet. If I had prior knowledge of these handy tips, my life would have been lot easier from day one on TPN.
8. Cathflo - The use of cathflo must be administered under supervision of a nurse or other healthcare professional only. This is a single use solution/medication that allows to clear occluded catheter when either a blood clot forms in the picc line or for any other reasons. For any serious conditions, I prefer to consult my home agency nurse.
9. Flushing - I have a silcon Groshong double lumen catheter and I flush the line with saline, heparin twice a day to keep it clean of bacteria. This should always be done with clean hands keeping the patient's hygiene in mind. When flushing the line, tip of both caps must be cleaned properly with alcohol swabs; squirt some liquid from saline and heparin syringes by holding vertically (to get rid of the air bubble) and then flush the solution very slowly with a gentle nudge through the cap into the catheter, I cover my caps with swab caps for extra protection.
10. Skin care - Since I use sorbaview 2000/mepilex dressing on my picc that provides multiple layers of comfort and protection to the skin, I also let fresh air go back and forth through my dressing and I also sit in sunlight to keep my skin cells healthy and breathing. I also find it safe to apply natural ointment, oil or moisturizer on my skin outside the border/periphery of my dressing and the rest of my right arm. I always wash and sanitize my hands before touching my site area. Always examine your PICC line site along with the dressing area for anything unusual like redness, swelling or itching/rashes and if you notice anything, take pictures if you can and report it to your nurse/home health agency immediately.
11. Atrial fibrillation - One time when my second piccline was placed in, I experienced severe fluttering in my heart area during infusion and I could not sleep all night and was worried. I spoke to my home agency nurse who suggested going to ER and the x-ray showed that tip of catheter was reaching atrium of my heart, the nurse pulled the line out by an inch and my symptoms subsided in a day. Even otherwise when I started fresh on TPN, I was too frail and underweight and would feel spasms and pain on slight movement and bending as I had a foreign object and it got better with time as my body got used to the piccline and TPN infusion both. It's always important to keep a track of all your symptoms on TPN and not take things lightly; it could help to talk to nurse, doctor or go to ER.
12. At times, there is a shortage of one or more of the ingredients that go into the bag, e.g. some vitamin or electrolyte. For e.g. While I have been on TPN, there was a shortage of calcium for almost 3-4 months and I was advised to use more oral calcium. Also, I want to share that TPN mix or multivitamins do not contain iron. I have been taking oral iron faithfully while I have been on TPN. When I was not aware of that, I had really bad RLS (restless leg syndrome) for almost 6-8 months and my Hgb (haemoglobin) levels dropped. My home health agency informs me whenever there is a shortage and we try to find alternatives.
13. Occlusion - There are one or more reasons for occlusion. When occlusion happens, the pump alerts with specific beeps. Very rarely, if the pump is malfunctioning, it can also beep without any real occlusion. But otherwise, some of the common reasons
for occlusion are:
14. Sometimes flushing the line and pulling out the saline syringe can create back pressure in the catheter and lead to blood flowing out into the catheter towards the caps. If this happens, I flush the line with enough saline. If it flushes well, nothing to worry about. If it does not flush well, I call my nurse. Below is a picture of what it looked like in my case.
15. It's critical not to stumble upon the tubing to avoid any fatal accidents and to keep the line from coming out. I connect the tubings to get more length for daytime infusion, tubing covers are also available if need be. Please see the "Pump setup video" for details on how I use it.
16. Reservoir volume > Infusion volume - The reservoir volume is the total volume of contents in the TPN bag. Infusion volume is the volume that will be infused into the patient and is always slightly less than the reservoir volume. After the infusion is over, the pump beeps and it is advisable to stop the pump and disconnect the tubing, then flush the line with saline to prevent clogging and then lock it with Heparin if needed.
17. Due to frequent urination on nighttime TPN, I used a commode chair on my bedside so I don't have to make trips to the bathroom all night long and feel less miserable when I need to sleep.
18. Line Safety/Migration - During dressing change, one step is to measure the length of the catheter from the insertion point using sterile measuring tape provided in most dressing kits. This is compared with the original length at the time of placement to make sure that the catheter has not migrated out of place. If it has, then it is recommended that we get an X-ray done to make sure that it is still in the SVC (superior vena cava) vein. Even if the line migrates out of place, it is not necessary that a patient might feel any symptoms but it is recommended that for patients on TPN, the catheter should end in the SVC. This is where the maximum supply of blood is available that is needed for the TPN mix. If by observation or by measurement, there is doubt that line has migrated, please contact your doctor/home health agency to arrange for an X-ray. They might ask you to continue infusion or stop it or reduce the rate as they feel appropriate. In the meantime, the X-ray will confirm if the line is in place or not. If it is not in place, sometimes, it is possible to move it back in place but most often, a new line might be needed, possibly in the same vein if the vein is not damaged by overuse.
If it has migrated out a little but is still in the SVC, you might be able to continue using the same line. However, the very idea of this website is to share tips to avoid such problems. My first line migrated out as the correct securement devices were not used. I had to get a second line placed. However, after that incident, I researched on all the available securement devices and requested my home health agency to provide me the Griplok. I have been using it for two years now. It has done the job of keeping my line in place. I also use steristrips. I could never use the Statlock, I have to admit that I hate it. It is very tedious to put it and remove it and also, it is very uncomfortable on my skin as well, causes blisters, itching and makes it hard to flex my arm. For more details on using Griplok to secure the PICC line, please view the "Dressing Change Video".
19. Lipids - When I first started on TPN, I was given 20gm lipids everyday mixed in my bags and within 2-4 days I started belching a lot and I didn't know why this happened and what to do about it. I then spoke to my dietician and requested them to reduce it to 10gms thrice a week, changes were made in my prescription after talking with my GI doc, and in few days time I felt some difference in the way I felt earlier. I also tried oral and IV mixed antacids but it caused itching in my case while sleeping at night, so now I have stopped using them in a long time. I use antacids only when I really need them. I personally feel that use of soy based lipids in IV mix is not a healthy idea as it can affect menstrual cycle adversely which is why I use very less of them.
20. Suture infection - In the hospital, my first PICC line was secured using sutures by the radiologist. After about a month, the sutures started going bad. The skin around the sutures started itching and became red. By the time the sutures were cut, it was too late and I had developed dermatitis on my PICC line site. Along with severe burning and itching, my skin also developed rashes and pus was oozing. When I went to the ER, I was told that I have skin infection called cellulitis and was given IV antibiotics. I was told that the line might have to be replaced. I decided to seek second opinion and I went to the wound care center at Georgetown hospital where they told me that it is not cellulitis, instead it is dermatitis and that my skin is reacting to the adhesive on the dressing. I was also told that it will heal on its own with the right care and that dressing change needs to be done more often while it is healing. I was also given a different dressing to use. I was told not to apply any antibacterial ointments on the PICC line site. I followed the instructions but the dermatitis had spread quite a bit and my skin was getting more irritated with the frequent dressing changes. At that time, my nurses were just using alcohol to remove the old dressing and not using an adhesive remover. The alcohol was causing a lot of burning and itching and further aggravating the dermatitis. Considering the situation, I decided to consult my naturopath doctor who specializes in homeopathy and I took the remedies he advised (Petroleum, Graphitis, Silicea) for the dermatitis. Homeopathy heals from inside out. Almost miraculously, within a week, my skin started healing. First the pus dried up, then the redness started to subside, then the broken patched skin started drying up and then it took 2-3 weeks for the rotten skin to be replaced by healthy pink skin. Within 4-6 weeks, it was healed. I am posting pictures of what my hand looked like with the dermatitis. Unfortunately due to the frequent dressing changes and lack of knowledge about the right securement devices, my PICC line migrated out during this time and it had to be replaced with a new line. Although I am glad, because this time around I pushed for a Groshong Silicone catheter. It had to be special ordered by the radiology department on my request as most hospitals only carry polyurethane catheters. However, silicone catheters are preferred over polyurethane for many reasons. I am happy with my catheter so far.
With a PICC line, there is always a possibility of sutures getting infected but line infection needs to be prevented at any cost, sepsis could be fatal. Ideally, there is no need for sutures in my opinion as the line can be secured using other safe securement devices like Griplok or steristrips. But in case, sutures cannot be avoided, it is advisable to get them cut and removed before they start going bad, else it can lead to dermatitis or skin infection. Once sutures are removed, the site should be secured using a securement device.
1. When I receive my TPN bags year round, I touch them to confirm they are cold enough and stay that way in refrigerator. Also during extreme weather conditions there are chances of delay of supplies delivery during transit, its a good idea to be in direct contact with home agency and have some kind of back up plan and I also keep some ice bricks handy for storing my bags in case of a power outage. My home agency is not in the same state where I live, so when I run into situations where I need spare bags I request them to send out some extra in advance or get it delivered by some near by home agency.
2. Avoid using expired bags and make sure fresh bags contain all ingredients from doctor's prescription, examine the bag carefully for anything unusual like leaks or cloudiness or floating particles. DO NOT keep the bag under direct sunlight, lamp or heat it up in a microwave. If needed, I run a towel in the dryer for 15 mins and then wrap it up around the bag or run some warm water over the bag to bring at room temperature.
3. Stat test - Sometimes blood reports can show drastic variation in levels and being on TPN, during these times patients are advised to get repeat testing done when there is emergency need. My doctor orders Stat test in such situations.
4. Stockinette medical - Sometimes, I use stockinette medical to secure my picc line and also keep the lumens from dangling while resting or doing any other activity. Regular stores carry cotton socks that can be used as well.
5. Blood draw - During the first year on TPN, I used to get blood work every week for some months and on biweekly basis/monthly thereafter. Now it's done every 8-10 weeks since my reports would come back normal, I requested my doctor to change the schedule and this also reduced the nursing visits. The blood work is done by Quest labs or Labcorp for me depending on coverage by insurance and the results are sent back to my home agency and I get a printed copy or email. I also prefer to replace the red cap soon after blood draw to avoid any bacterial growth, this protocol is followed by most people.
6. Shower sleeve - It is a huge challenge to take a shower with a PICC line. Shower sleeves are available and I tried a few but none of them worked for me. So I found this tip from Oley.org where it was recommended to use "Press n Seal". I have been doing that for 2 yrs with some additions and it has worked out well to keep my line dry after a shower. Press n Seal from Glad is available in all common food stores. It is a see through plastic wrap that sticks very well to the skin and this is a link, http://www.glad.com/food-storage/plastic-wrap/press-n-seal/ .
7. Tubing - When I was doing nighttime infusion, I used a single CADD tubing for a long time and I had no option but to hear the annoying sound that the pump made. We tried using travel bags to keep my bagpack but nothing really worked. Later after many trials, my agency sent microbore extension set so I could attach them and keep my bagpack in my room closet. If I had prior knowledge of these handy tips, my life would have been lot easier from day one on TPN.
8. Cathflo - The use of cathflo must be administered under supervision of a nurse or other healthcare professional only. This is a single use solution/medication that allows to clear occluded catheter when either a blood clot forms in the picc line or for any other reasons. For any serious conditions, I prefer to consult my home agency nurse.
9. Flushing - I have a silcon Groshong double lumen catheter and I flush the line with saline, heparin twice a day to keep it clean of bacteria. This should always be done with clean hands keeping the patient's hygiene in mind. When flushing the line, tip of both caps must be cleaned properly with alcohol swabs; squirt some liquid from saline and heparin syringes by holding vertically (to get rid of the air bubble) and then flush the solution very slowly with a gentle nudge through the cap into the catheter, I cover my caps with swab caps for extra protection.
10. Skin care - Since I use sorbaview 2000/mepilex dressing on my picc that provides multiple layers of comfort and protection to the skin, I also let fresh air go back and forth through my dressing and I also sit in sunlight to keep my skin cells healthy and breathing. I also find it safe to apply natural ointment, oil or moisturizer on my skin outside the border/periphery of my dressing and the rest of my right arm. I always wash and sanitize my hands before touching my site area. Always examine your PICC line site along with the dressing area for anything unusual like redness, swelling or itching/rashes and if you notice anything, take pictures if you can and report it to your nurse/home health agency immediately.
11. Atrial fibrillation - One time when my second piccline was placed in, I experienced severe fluttering in my heart area during infusion and I could not sleep all night and was worried. I spoke to my home agency nurse who suggested going to ER and the x-ray showed that tip of catheter was reaching atrium of my heart, the nurse pulled the line out by an inch and my symptoms subsided in a day. Even otherwise when I started fresh on TPN, I was too frail and underweight and would feel spasms and pain on slight movement and bending as I had a foreign object and it got better with time as my body got used to the piccline and TPN infusion both. It's always important to keep a track of all your symptoms on TPN and not take things lightly; it could help to talk to nurse, doctor or go to ER.
12. At times, there is a shortage of one or more of the ingredients that go into the bag, e.g. some vitamin or electrolyte. For e.g. While I have been on TPN, there was a shortage of calcium for almost 3-4 months and I was advised to use more oral calcium. Also, I want to share that TPN mix or multivitamins do not contain iron. I have been taking oral iron faithfully while I have been on TPN. When I was not aware of that, I had really bad RLS (restless leg syndrome) for almost 6-8 months and my Hgb (haemoglobin) levels dropped. My home health agency informs me whenever there is a shortage and we try to find alternatives.
13. Occlusion - There are one or more reasons for occlusion. When occlusion happens, the pump alerts with specific beeps. Very rarely, if the pump is malfunctioning, it can also beep without any real occlusion. But otherwise, some of the common reasons
for occlusion are:
- Kinking of the tubing - examine the tubing for any visible kinks and straighten them.
- Air bubble in the tubing - prime carefully to avoid air bubbles and if there seems to be an air bubble stuck in the tubing, we can disconnect the tubing and prime again to clear the air bubble and reconnect.
- Settings of the pump - Sometimes, the pump settings are not correct and a slight change in pressure can cause occlusion. (Check with your home health agency).
- Clot in the catheter - Sometimes, the catheter can get blocked causing obstruction in the flow of TPN and thereby causing occlusion. Flush the line with enough saline, if that does not clear it, you may have to use Cathflo.
14. Sometimes flushing the line and pulling out the saline syringe can create back pressure in the catheter and lead to blood flowing out into the catheter towards the caps. If this happens, I flush the line with enough saline. If it flushes well, nothing to worry about. If it does not flush well, I call my nurse. Below is a picture of what it looked like in my case.
15. It's critical not to stumble upon the tubing to avoid any fatal accidents and to keep the line from coming out. I connect the tubings to get more length for daytime infusion, tubing covers are also available if need be. Please see the "Pump setup video" for details on how I use it.
16. Reservoir volume > Infusion volume - The reservoir volume is the total volume of contents in the TPN bag. Infusion volume is the volume that will be infused into the patient and is always slightly less than the reservoir volume. After the infusion is over, the pump beeps and it is advisable to stop the pump and disconnect the tubing, then flush the line with saline to prevent clogging and then lock it with Heparin if needed.
17. Due to frequent urination on nighttime TPN, I used a commode chair on my bedside so I don't have to make trips to the bathroom all night long and feel less miserable when I need to sleep.
18. Line Safety/Migration - During dressing change, one step is to measure the length of the catheter from the insertion point using sterile measuring tape provided in most dressing kits. This is compared with the original length at the time of placement to make sure that the catheter has not migrated out of place. If it has, then it is recommended that we get an X-ray done to make sure that it is still in the SVC (superior vena cava) vein. Even if the line migrates out of place, it is not necessary that a patient might feel any symptoms but it is recommended that for patients on TPN, the catheter should end in the SVC. This is where the maximum supply of blood is available that is needed for the TPN mix. If by observation or by measurement, there is doubt that line has migrated, please contact your doctor/home health agency to arrange for an X-ray. They might ask you to continue infusion or stop it or reduce the rate as they feel appropriate. In the meantime, the X-ray will confirm if the line is in place or not. If it is not in place, sometimes, it is possible to move it back in place but most often, a new line might be needed, possibly in the same vein if the vein is not damaged by overuse.
If it has migrated out a little but is still in the SVC, you might be able to continue using the same line. However, the very idea of this website is to share tips to avoid such problems. My first line migrated out as the correct securement devices were not used. I had to get a second line placed. However, after that incident, I researched on all the available securement devices and requested my home health agency to provide me the Griplok. I have been using it for two years now. It has done the job of keeping my line in place. I also use steristrips. I could never use the Statlock, I have to admit that I hate it. It is very tedious to put it and remove it and also, it is very uncomfortable on my skin as well, causes blisters, itching and makes it hard to flex my arm. For more details on using Griplok to secure the PICC line, please view the "Dressing Change Video".
19. Lipids - When I first started on TPN, I was given 20gm lipids everyday mixed in my bags and within 2-4 days I started belching a lot and I didn't know why this happened and what to do about it. I then spoke to my dietician and requested them to reduce it to 10gms thrice a week, changes were made in my prescription after talking with my GI doc, and in few days time I felt some difference in the way I felt earlier. I also tried oral and IV mixed antacids but it caused itching in my case while sleeping at night, so now I have stopped using them in a long time. I use antacids only when I really need them. I personally feel that use of soy based lipids in IV mix is not a healthy idea as it can affect menstrual cycle adversely which is why I use very less of them.
20. Suture infection - In the hospital, my first PICC line was secured using sutures by the radiologist. After about a month, the sutures started going bad. The skin around the sutures started itching and became red. By the time the sutures were cut, it was too late and I had developed dermatitis on my PICC line site. Along with severe burning and itching, my skin also developed rashes and pus was oozing. When I went to the ER, I was told that I have skin infection called cellulitis and was given IV antibiotics. I was told that the line might have to be replaced. I decided to seek second opinion and I went to the wound care center at Georgetown hospital where they told me that it is not cellulitis, instead it is dermatitis and that my skin is reacting to the adhesive on the dressing. I was also told that it will heal on its own with the right care and that dressing change needs to be done more often while it is healing. I was also given a different dressing to use. I was told not to apply any antibacterial ointments on the PICC line site. I followed the instructions but the dermatitis had spread quite a bit and my skin was getting more irritated with the frequent dressing changes. At that time, my nurses were just using alcohol to remove the old dressing and not using an adhesive remover. The alcohol was causing a lot of burning and itching and further aggravating the dermatitis. Considering the situation, I decided to consult my naturopath doctor who specializes in homeopathy and I took the remedies he advised (Petroleum, Graphitis, Silicea) for the dermatitis. Homeopathy heals from inside out. Almost miraculously, within a week, my skin started healing. First the pus dried up, then the redness started to subside, then the broken patched skin started drying up and then it took 2-3 weeks for the rotten skin to be replaced by healthy pink skin. Within 4-6 weeks, it was healed. I am posting pictures of what my hand looked like with the dermatitis. Unfortunately due to the frequent dressing changes and lack of knowledge about the right securement devices, my PICC line migrated out during this time and it had to be replaced with a new line. Although I am glad, because this time around I pushed for a Groshong Silicone catheter. It had to be special ordered by the radiology department on my request as most hospitals only carry polyurethane catheters. However, silicone catheters are preferred over polyurethane for many reasons. I am happy with my catheter so far.
With a PICC line, there is always a possibility of sutures getting infected but line infection needs to be prevented at any cost, sepsis could be fatal. Ideally, there is no need for sutures in my opinion as the line can be secured using other safe securement devices like Griplok or steristrips. But in case, sutures cannot be avoided, it is advisable to get them cut and removed before they start going bad, else it can lead to dermatitis or skin infection. Once sutures are removed, the site should be secured using a securement device.
my very first picc line
|
site skin started to rot causing blisters, burning, itching and pus due to suture infection after 5 weeks of having my line
|
redness and flaky skin around the site but healing begins
|
catheter migrated out during the time skin was healing
|
IV3000 dressing and gauze that I used during this phase
|
process of healing goes on
|
my right arm is puffy and redness persists
|
keeping site secure with gauze, biopatch etc
|
keeping site secure with socks, biopatch etc but line needed to be taken out
|
skin close to insertion point is healing better
|
sorbaview dressing and a close up view
April 12, 2013- reverse pressure blood flow into the catheter towards the caps and tubing
|
On Jan 10, 2011 my Groshong catheter was placed in 6 weeks after dermatitis started
|
closer view of my second picc line
|
closer view when infusion
going on and the line kept
fully secure
|
Internet has a lot of important information that may be useful while managing TPN at home. Nowadays, social media has become very popular for medical links as well. I also think doing self research on internet, phone, word of mouth helps. In past few years that I have been on TPN, initially many nurses were assigned to me. It is a matter of great luck to find an experienced infusion nurse who is skilled, polite and kind and is open minded. I tried to put my full faith into them but over a period of time I realized that having a PICC line and being on TPN, I had to be extremely active in my own line care and I cannot rely on any one person, no matter how skilled they are. As complicated as this process is, no one person can possibly know everything about it. I was turned down by most primary care physicians as they did not feel comfortable having a patient with a PICC line. I was always told to go to the ER, even for simple orders like X-rays. The nurses also had different types/rules of training on dressing change, cap change, blood draws and using Cathflo. After a lot of struggle and after losing one line due to migration, I started doing more research and started asking more questions. My home health agency was extremely supportive of my questions and never turned me down for a request that was reasonable and backed up by research. I never thought that we would take over my dressing and cap change but that decision was the best decision I made for my line care. Now I feel safe and confident. I feel in control of my line and its care and I know I am doing the best possible. If I run into situations where I need advice or help, I ask for it. I take second opinion if needed. Earlier I used to hesitate but now I don't. Even when I went to the ER, I had the confidence to tell the attending doctor to put on a mask and wear gloves before attending to my PICC line. Another piece of wisdom or tip I got is that most big hospitals have PICC line nursing teams who are very knowledgeable about PICC line care. They specialize in this field and have a lot of experience troubleshooting PICC line issues. However, once again, I ask many questions. I make sure I understand the "what", "why" and "how" before I do anything with my PICC line. Information exchange is always bi-directional. There are times when we can provide tips to our nurses and doctors by sharing our experience with them. And although most times, we can trust the medical information being provided to us, there are times when we have to trust our gut feeling.
Fortunately, I have a wonderful team who is open minded. My only advice would be, "Ask questions", "Do not hesitate". Sometimes, you might have to be rude. You can always apologize later. We are all humans. Even the doctor and the nurse are humans, they can make mistakes. And you/we can too. But many mistakes can be avoided if we ask the right questions and take charge/responsibility.
Fortunately, I have a wonderful team who is open minded. My only advice would be, "Ask questions", "Do not hesitate". Sometimes, you might have to be rude. You can always apologize later. We are all humans. Even the doctor and the nurse are humans, they can make mistakes. And you/we can too. But many mistakes can be avoided if we ask the right questions and take charge/responsibility.