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RE: normal saline vs. D5W with IVIG..SO Angry!

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Sue,

That is HORRIBLE!!! How scary.I am sooo glad your sister caught the

mistake.is there anywhere else you can go? Should you report something like

that to her supervisor? Not so much the mistake but then trying to cover

what she had done.yikes!! She was definitely messing with the wrong

people!!! e is so lucky to have you and your sister.

Jeane

From: [mailto: ] On Behalf Of

Sue Bordelon

Sent: Thursday, July 22, 2010 9:30 PM

Subject: normal saline vs. D5W with IVIG..SO Angry!

Hi everyone...my son receives ivig Gamunex every two weeks.....his usual

nurse, who's been giving him the infusion for the past year, always uses an

IV bag of D5W for the remainder to be flushed from the Burretrol,tubing and

chamber. I read in the prescribing information pages, this is the approved

fluid to be used with Gamunex.

Well, today, the new nurse there hung a bag of Normal Saline, mixed with the

remainder of the IVIG and turned it on as a flush. My sister noticed the

mistake and quickly told the nurse. She started stumbling on her wods... " uh,

well, the pharmacist said it was OK, we don't have any more D5Wbags, uh,

it's OK. " (I hate liars!!! especially when they're messing with my child's

health!)

I called the pharmacy, of course, the nurse was lying, the pharm said he did

not tell her it was OK because it's not! The manufacturer specifically has

written THREE times in the info " Incompatible with Normal Saline. "

My sister turned the pump off, demanded his port be flushed and we left. I

called Talecris and they said it is not compatible with normal saline, I

also called Accredo, the pharmacist said the same thing.

I am SO Angry!!!!!! The nurse lied then tried to lie to get out of her

mistake......!!!!

I am an RN for 25 years, I've seen how deceptive and careless some people

can be ....

I have lost all trust for this ped infusion clinic...trying to decide what

to do next......thanks, Sue

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Thank you Jeane...I am still so upset, thanks for being supportive. I think

I will take it further, to the administration. Here's a letter I sent to the

nurses and the hematologist there:   hugs,Sue

Here is the link for the prescribing info from Talecris, Gamunex

manufacturer. I know ya'll were looking at it at the desk, but I'm

enclosing it here again for you.

http://www.gamunex.com/media/Gamunex_Prescribing_Info.pdf

This is why were concerned...when

Dessauer hung the N.S. flush bag, there was still about 5 cc

of the IVIG in the Buretrol, the chamber was full and the tubing was all

Gamunex, all the way to e's port. Of course mixing would occur!

Talecris specifically writes in its prescribing and administration information

that Gamunex is Incompatible with Normal Saline.  And Normal Saline was what

was hung on my son.

In Section 2.1 of the attached page from Talecris, it says " Gamunex is not

compatible with saline. "

In Section 2.5 attached, under the heading " Incompatibilities " it states

" Gamunex is NOT compatible with saline. "

In Section 7 attached, it instructs the administering person to " Flush with

D5W. "

So,

when Dee noticed that the Normal Saline was the flush bag, mixing with

the Gamunex, she alerted

those at the desk. She was told that ya'll had run out of D5W, and that

the pharmacist said it was OK. (I called the Ochsner IV pharmacist who

said that no one had called about this!)

I called the Pharmacist at Accredo who said " Absolutely NOT, they are

incompatible. Stop the NS now and detach it from the Gamunex! "

I called Talecris and they said it is because of the

incompatibility with the stabilizing agent. " Saline and Gamunex should not

mix. "

If you were lacking a flush bag of NS for another child who had just

completed a blood transfusion, would you substitute it with D5W

instead?! Of course not! So why did you think that was OK to do to

e?

e has been receiving his IVIG there for a year...in

that time, he has not had one acute infection that required

hospitalization. (just the cdiff and chronic MRSA)  We have been so

grateful for the care.

I wish I could explain to you

that this has been life-changing for e...he can go places and not

get sick, he no longer has awful otitis media bouts every month, nor frequent

sinus infections

nor pneumonias, and  he can go to school without catching everything

and winding up in the ER. The IVIG has been a life-giving thing for

him.... DeFrisco knows how important this is to e's

health.  We are very appreciative of the care there.

Mistakes

happen....but why excuses, why lies, just fix it....so if there was no

D5W in the clinic why didn't somebody get some???  Why risk a problem

with e's health? Is he not as important as the other kids you have

to go get IV fluids

for? ...We would have gladly driven someone to pick it up if this was the case.

Why take a chance with e??

This is so very hurtful and infuriating at the same time.

Sue Bordelon

From: Jeane <maryjeanedavis@...>

Subject: RE: normal saline vs. D5W with IVIG..SO Angry!

Date: Friday, July 23, 2010, 5:23 AM

 

Sue,

That is HORRIBLE!!! How scary.I am sooo glad your sister caught the

mistake.is there anywhere else you can go? Should you report something like

that to her supervisor? Not so much the mistake but then trying to cover

what she had done.yikes!! She was definitely messing with the wrong

people!!! e is so lucky to have you and your sister.

Jeane

From: [mailto: ] On Behalf Of

Sue Bordelon

Sent: Thursday, July 22, 2010 9:30 PM

Subject: normal saline vs. D5W with IVIG..SO Angry!

Hi everyone...my son receives ivig Gamunex every two weeks.....his usual

nurse, who's been giving him the infusion for the past year, always uses an

IV bag of D5W for the remainder to be flushed from the Burretrol,tubing and

chamber. I read in the prescribing information pages, this is the approved

fluid to be used with Gamunex.

Well, today, the new nurse there hung a bag of Normal Saline, mixed with the

remainder of the IVIG and turned it on as a flush. My sister noticed the

mistake and quickly told the nurse. She started stumbling on her wods... " uh,

well, the pharmacist said it was OK, we don't have any more D5Wbags, uh,

it's OK. " (I hate liars!!! especially when they're messing with my child's

health!)

I called the pharmacy, of course, the nurse was lying, the pharm said he did

not tell her it was OK because it's not! The manufacturer specifically has

written THREE times in the info " Incompatible with Normal Saline. "

My sister turned the pump off, demanded his port be flushed and we left. I

called Talecris and they said it is not compatible with normal saline, I

also called Accredo, the pharmacist said the same thing.

I am SO Angry!!!!!! The nurse lied then tried to lie to get out of her

mistake......!!!!

I am an RN for 25 years, I've seen how deceptive and careless some people

can be ....

I have lost all trust for this ped infusion clinic...trying to decide what

to do next......thanks, Sue

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I myself have had this happen to me on two different times with my daughter. 

We are getting in home infusions.  We just got a new nurse and when she left

after my daughter's last infusion I found the two tubes of the D5W laying in

the bag on the table.  So I know she was not flushed with them.  Normal saline

was used.  It has worried me because it does say  Gamunex is Incompatible with

Normal Saline.  However it does not say what can happen if it is used. 

 

When this happen the first time we caught her and told her no you need to use

D5W.

Pat

Accounting Manager

PNR Transport & Logistics

PH: 607-583-2458

FAX: 607-583-2549

From: Jeane <maryjeanedavis@...>

Subject: RE: normal saline vs. D5W with IVIG..SO Angry!

Date: Friday, July 23, 2010, 5:23 AM

 

Sue,

That is HORRIBLE!!! How scary.I am sooo glad your sister caught the

mistake.is there anywhere else you can go? Should you report something like

that to her supervisor? Not so much the mistake but then trying to cover

what she had done.yikes!! She was definitely messing with the wrong

people!!! e is so lucky to have you and your sister.

Jeane

From: [mailto: ] On Behalf Of

Sue Bordelon

Sent: Thursday, July 22, 2010 9:30 PM

Subject: normal saline vs. D5W with IVIG..SO Angry!

Hi everyone...my son receives ivig Gamunex every two weeks.....his usual

nurse, who's been giving him the infusion for the past year, always uses an

IV bag of D5W for the remainder to be flushed from the Burretrol,tubing and

chamber. I read in the prescribing information pages, this is the approved

fluid to be used with Gamunex.

Well, today, the new nurse there hung a bag of Normal Saline, mixed with the

remainder of the IVIG and turned it on as a flush. My sister noticed the

mistake and quickly told the nurse. She started stumbling on her wods... " uh,

well, the pharmacist said it was OK, we don't have any more D5Wbags, uh,

it's OK. " (I hate liars!!! especially when they're messing with my child's

health!)

I called the pharmacy, of course, the nurse was lying, the pharm said he did

not tell her it was OK because it's not! The manufacturer specifically has

written THREE times in the info " Incompatible with Normal Saline. "

My sister turned the pump off, demanded his port be flushed and we left. I

called Talecris and they said it is not compatible with normal saline, I

also called Accredo, the pharmacist said the same thing.

I am SO Angry!!!!!! The nurse lied then tried to lie to get out of her

mistake......!!!!

I am an RN for 25 years, I've seen how deceptive and careless some people

can be ....

I have lost all trust for this ped infusion clinic...trying to decide what

to do next......thanks, Sue

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