4 Sloppy IV Mistakes You Should Avoid
One of the nice perks I’ve found to blogging is that every now and then I get to rant. This piece might fit into that rant category. Not necessarily the full blown, foot stompin’, leave the caps lock key on, kind of rant, but a rant none the less.
I’ve started a bunch of IVs. Some were really good. Some were, I can’t believe I got that, there must have been some divine intervention involved, good. Of course I never say anything like that at the time. I tape it down nonchalantly and act like I get the hard ones all the time.
I’ve had my share of bad ones as well. I’ve missed IVs in veins so big that I should have been able to throw the needle dart style and still hit the vein. I’ve chased veins across peoples arms and left them with bruises to remember me by for weeks to come. I’m not proud of it, but I’ll take ownership of it. IVs aren’t my favorite thing to do. I didn’t become a caregiver because I liked causing people discomfort with needles. (Though some of my patients have seemed convinced otherwise.)
Along the way I’ve picked up some pet peeves about starting IVs and I’d like to share them with you. This is a list of my top four, please don’t do this, IV pet peeves.
When starting an IV please:
Don’t blame your missed IV on the patients veins.
This is an insidious habit. I don’t care what the patients veins look like. I don’t care if they are buried, if they roll of if they dance around like a hula girl. The patient didn’t miss the IV … you did. Don’t ever tell the patient, “You have brittle veins, deep veins, small veins, rolling veins.” (Whatever that means) or anything else to make it seem like the missed IV is the patients fault and not yours.
If you miss it, you miss it. Say sorry and move on. Those pitiful remarks about the patient being a hard stick will only make you look worse. Other popular versions of this bad habit are the medical history question asked right after the failed attempt, “Are you on blood thinners?” or looking aggravated at the drivers compartment as if to suggest that something in your partners driving cause your failure. Suck it up. Correctly document the failed attempt (hopefully on your free EMR) and move on.
Don’t clean the puncture site and then touch it again with your dirty glove or finger.
I know how it goes. You massage the vein. You poke the vein. Then you poke at it a little more. You feel it under there just waiting for your needle. You pick your angle and site of attack and then you dutifully swab the area to prep it before you stick. And then … you just have to touch it again.
I know. Believe me I know. Sometimes the urge is just irresistible. You want just one more feel of that vein to confirm it’s still there waiting for you. But don’t. You’re only recontaminating the site. Trust yourself. Trust the vein. It didn’t leave for vacation while you were picking up the needle. It’s waiting for you. Just stick.
Don’t ask the patient to open and close their hand
- It does nothing.
- No … really. It does nothing. (If you really want to, hang their arm down. That stands a much better chance of making a noticeable difference in vein size.)
Don’t blow the vein and then leave the tourniquet on while you look for a 4X4 etc.
We all blow veins. It’s never pretty when it happens. But when you see the vein blow, the very next move should be to pop that tourniquet. This will decrease the amount of bruising and swelling the patient experiences.
I see folks make this error all the time. The vein is blown. They know the vein is blown and the start looking around for the gauze 4X4. Then they do the one handed maneuver to tear open the package. Then they put pressure on the wound and remove the IV needle. Then at some point, while trying to stop the flow of blood they reach up and pop the tourniquet.
Pop the tourniquet first. Your patient might not thank you but I will.
I know all of these sloppy errors well. They are all bad IV habits that I had to break for myself at one time or another. Now I urge you to do the same.
I think I have my little problem with my comments box fixed. Give it a try. I’d love to hear what you think about sloppy errors or pet peeves with IV start technique or anything else.
Steve
Tags: advice, errors, establish, iv, pet peeves, skill, start, technique
Steve,
Thanks for the reminder! Having been under the care of medical professionals who have made all of the above mistakes, I’ve got a huge amount of sympathy for patients in general. The nurse who kept the stylet in my arm and dug around for 10 minutes *yep, it was timed* trying to get access into my intern vein while commenting “oops, it keeps rolling, just hang on while I try again” convinced me that your patient’s comfort is far more important than your personal first stick record. If you can’t get it, then admit it and move on. Going to IV approval school gave me a new outlook on the issue, and now I have an equal amount of sympathy for the providers stuck (no pun intended) with a patient with difficult veins. All of your rules are things that I’ve caught myself doing, and I’m trying to break myself of the tendencies before they are full blown habits. Under # 3, I’d also add “please, don’t slap/flick the vein you’ve selected.” This especially applies if you have an elderly patient or one undergoing chemotherapy, as their skin can be fragile and their veins have an increased tendency to blow, at least in my limited experience.
I’m really enjoying the site, keep up the great work!
Jen
Great points Jennifer. Yes, I agree that slapping the vein is about as useful as opening and closing the hand. Thanks for the reply.
Sooo, Licking the needle before insertion for good luck is still ok. Right?
I actually had a temp partner miss and blame the patients answering my of questions. He didnt get a second attempt.
I had a patient ask me if I just enjoyed tourturing people with needles (before I even attempted the first IV on her). I did get the IV first try (lucky for me) but I had to stop and laugh a little. All good pointers Steve, thanks!
Yesterday I had an IV inserted preceding a CT scan. I told her it felt tight where she repeatedly flushed it to see if it was in. Then she called the ‘expert’ and she flushed it and said it was good. Off to the scanner, and the IV juice. She left the room to start x raying, and my arm and wrist were really starting to hurt. I looked and they were so swollen up they looked like they were going to blow. I hollered and she ‘took her time’ came in and slooooooooowly turned off the drip.
Ending: My arm swollen to maximum capacity from hand to elbow, a 2 hour drive home in pain so bad I cried the entire way. It was a bad day in bedrock:(
PS: They wanted to reschedule, I declined..
Today, I went to kaiser for a pre-op physical. The nurse poked the top of my hand to get blood and she missed so she pulled the needle partially out, re-angled it and tried again and missed. She did this like 4 more times and never got a drop of blood but I did feel her poke something she shouldn’t have and I it hurt so bad that I who claim to have a high tolerance to pain began to sweat. The area developed a large swelling and I am unable to move my index finger, middle finger and fourth finger. Putting any weight on them hurts like hell so if I try to lift myself up, it brings tears to my eyes. I have iced the area and run hot water on it and the swelling remains firm. There is a large knot like swelling around the area where she poked me. Did she hit a nerve? What did she do to make this swelling occur and cause my fingers to hurt like I twisted them? There is no discoloration, just swelling and the finger problem and pain. Help!!! What can I do to get rid of this quick. I need my hands to lift myself up after a total right hip replacement (I just had my left done a few weeks ago and my hands were so needed to lift myself up from a chair, lower myself down onto the chair or bed, hold the walker etc). I have a week, will this go away?
Great peeves Steve. I always enjoy when people smack the arm a bunch of times. The site prep peeve is funny though and I find myself almost doing that when starting IV’s. I actually put together a report on difficult IV access and got a bunch of great tips from field providers. I wish I knew your site was up then. Maybe I’ll update it and put your comments in. It is a free report on my site.
Keep up the great posts.
Jim
Ummm this is a cool site so I felt that I wanted to post a vent, not about nurses or medics, but about patients.
People, seriously. (I see this all the time).
If you have 10000000 tatoos on your body…why must you cry and scream about a tiny butterfly in your AC?
That is such a pet peeve of mine.
Who puts a butterfly in an AC?
Seriously, that’s what a 14ga is for.
No, I don’t use anything much bigger than a 20 routinely… but really? A butterfly?
Remember, if you tie up the AC with a smaller needle and the patient crashes then you will need to find another place to get a big needle in.
Ckemtp, that’s what the Ez-IO is for…just kidding! I agree with you 100%.
Steve, here are a few others you can add to your list.
1. Once you have attempted once and missed, discard the IV cath and try again with a NEW one. It’s now no longer sterile and the tip is now a bit more dull.
2. When you set up your bag and tubing, do not remove the cap from the tubing until just before connecting it to your patient. Don’t let it flop around on the bench seat, floor, or wall…picking up God-knows-what type of bacteria along the way. I routinely ask providers “would you want that IV connected to you after the tip fell onto the floor?”. They usually get the point.
Ooooh, taking the cap off early, that is a particularly naughty habit. I’ve never understood that one.
Ah yes. The tattooed man who’s scared of needles. I think we’ve all had that dude at some point. (No pun intended.)
Steve, just wrote a somewhat related post. Shot ya a link.
How about using your teeth when pulling the caps off the tubing before spiking the back or when taking the end off the tubinh before connecting it? I have been guilty of it, it’s how I was taught and never thought about, then I wised up, realizing how gross that is, I wouldnt want that hooked up to my IV if I was the pt….I am still working (and getting better) at the touching-the-site-after-cleaning-it bad habit…
Thanks for the posts!!
@Ckemtp, Thanks my friend.
@WV medicgirl, I used to do that too. Then one day I came inches from inserting the bloody cap in my mouth on a trauma call. It was so ingrained in my muscle memory. Now I have the rule that nothing goes in my mouth during patient care. Great one.
Taking the cap off with my teeth was something that I did for years and have recently stopped, although, it probably isn’t all that bad since your mouth never touches the sterile end. Think about it, that cap can roll around on the bench seat for all we care and the sterile tip never gets contaminated.
I agree, however, that this is just sloppy form, but even after having quit that for the last couple of years, its still an awkward excercise taking that cap off while tamponading the vein and holding the hub. I think I’ve probably accidentally touched the tip with my glove more than once since I have decided to do this part of the excercise one handed. Any suggestions?
Zach, don’t use your mouth bud … just don’t. It isn’t that you’re going to contaminate the tip, it’s that your sticking the cap in YOUR mouth. After it rolls around on the filthy bench, after it touches your dirty gloved hand, after it sits on the patients lap or leg (yuck).
That cap can be disgustingly dirty and (at worst) be contaminated with blood and body fluid. My advice is to never put anything that has been in the back of an ambulance in your mouth.
I pinch the cap between the knuckles of my pointer and middle finger on the hand that is tamponading the vien to remove the cap.
I’ll be sure to remember these when I’m sitting in my IV certification this weekend. Thanks Steve!
Aw hey Dan, that’s awesome. Tear it up. Now you’ve got the inside track. Always good to hear from you.
Thanks Steve I will. Let me know when you need me to help test your new students
Thanks for this insight. I am not an EMT or EMS I am a patient who just had my first blown vein & it scared the crap out of me. I don’t know how you guys do this anyway & I really don’t see how people can shoot drugs up. I don’t even know how to find my own vein much less someone elses. Anyway I was at the E.R. for some test’s to see why I have been blacking out & they were trying to get an IV started & I guess since I am paralyzed & my hands are drawn up they had problems or something. But obviously they shouldn’t have tried starting an IV in my hand. Anyway, the guy blew my vein & a huge knot came up on my hand & blood was coming out everywhere & I freaked big time. They had to come in and get an IV started in my arm quickly & give me liquid valium to calm me down. Even then they still didn’t fully explain what a blown vein was & if there was anything I should or shouldn’t do for the next week or so. They had royal peeved me off & I would have had that IV ripped out of my arm & been out of there if they hadn’t caught me. But thanks for this info. it has helped knowing that it is common in some ways & that it is supposed to hurt. However since it was in my hand, should my upper arm be hurting in pain especially to the touch. You know, the area where most people get their B-12 injections, up around the upper arm? I haven’t had my B-12 in almost a month now so I know that it’s not from that so should that area be hurting from the blown vein as well? Will the vein be allright or is it going to die off? I am paralyzed with Lou Gehrig’s Disease & Progressive Spinal Cord Dysfunction & Spinal Cord Compression in three different areas of my spine (C-spine, T-Spine, & L-Spine compression on the Cord). Thank you very much for posting this website, you should feel proud knowing that you have not only helped fellow EMT’s but also at least one patient. Not sure which state you are in but I am in Alabama, that’s how far this information has made it.
Ckemptp: Nursey Nurse was probably referring to a butterfly used for a lab draw rather than an IV. That’s pretty much all nurses use butterflys for.
BTW….great info!
Thanks for posting this…especially the part about missing the huge veins. There are times I hit a spider vein in an 80-y/o diabetic undergoing chemotherapy cause that is my only shot…and other days when I miss the 20-y/o construction worker whose small veins could hold a 14 gauge! :-/
When I was learning to start IV’s, I would say a quick prayer for success in my head before I stuck, and I would miss the IV EVERY time. One of my co-workers said “Maybe God wants you to KNOW you can do it…not pray that you can.” So now I stick with confidence…and then praise God for the success afterward.
Physicians always recommend filling up on fluids before a blood drawn to help prevent dehydration & collapsed veins. I’m a patient who usually has NO problem with blown veins. However, just prior to surgery this week, they instructed me to stop all food and fluid intake @ midnight before surgery day, which meant 10 hours with no fluids before check-in and pre-op prep (IV insertion). They blew two veins, then doubled-up the IV with the BP cuff on the same arm, blowing a third vein while I lay there screaming through clenched teeth. What could I have done to help avoid this, especially since I was told to NOT drink any water ahead of time? It’s been 2 days, and my hands are still swollen & sore. I had sugery on both my legs, so have to use crutches for mobility, but it’s nearly impossible with two sore hands. What can I do to speed healing at this point?
I am a pregnant patient and have to get my blood drawn frequently for prenatal care. My last visit was last week and the nurse opened the packaged butterfly iv to draw blood but dropped it onto the floor. There was a thin plastic covering and the tubing was still on the needle. The only thing that peeved me was that she used her foot to try to get the needle because it was under a table. Should the needle still be sterile even though she did that even with the thin plastic covering and tube? I have to get my blood drawn again tomorrow 4 times because I didn’t pass my initial sugar test so I am to
I am a pregnant patient and have to get my blood drawn frequently for prenatal care. My last visit was last week and the nurse opened the packaged butterfly iv to draw blood but dropped it onto the floor. There was a thin plastic covering and the tubing was still on the needle. The only thing that peeved me was that she used her foot to try to get the needle because it was under a table. Should the needle still be sterile even though she did that even with the thin plastic covering and tube? I have to get my blood drawn again tomorrow 4 times because I didn’t pass my initial sugar test so I am totally dreading it!
I just found this post. As an infusion nurse, I have the same issues with the points you brought up. One other thing is, don’t keep sticking patients hoping to eventually find a vein. There are limits, 2 unsuccessful attempts. Great post!
Thanks,
Cora Vizcarra RN, CRNI
@infusionnurse
can I insert the hep lock myself? I am pregnant and I have Anti Phospholipid Antibody Syndrome.
@jesselei Well, uh, there are a coupe of ways to approach that question. From the standpoint of possibility, yes, it is physically possible to start an IV on yourself.
While learning IVs in paramedic school myself and several of my classmates succeeded in ill-advised attempts to start IVs on ourselves. For a trained medical professional, it’s a hard thing to do. If you aren’t trained to start the on other people, starting one on yourself would be very difficult. And, likely, painful.
No competent medical person is going to let you start your own IV hep-lock before your procedure. If you started your own before you showed up for the procedure they probably wouldn’t use it, unless you had a really good rapport with them and they confirmed it was good. And then they’d tell you not to do that again.
My concern is why you think this would be a good idea? I’ve started thousands of IVs and, if I need one, I’m more than happy to have someone else start it. It would be quicker and less painful.
What gives?
Just wanted to leave a general note here. I have HUGE veins in my arms, no one that has drawn my blood over my entire life has ever managed to blow a vein. Until this past friday that is. This girl not only managed to “roll” one vein. (she was nice enough to tell me thats what she did, like it was my fault). Then she proceeds to stick me in the SAME arm in a vein that was really close to the original vein she just damaged. She managed to somehow “back” that one up. All I could think was o crap this is not going well! As a pt there are many things I would suggest to this lady.
A.) When you see huge veins, don’t get cocky and think you’re going to be great. Treat my like any other pt.
B.) Once you blew the first vein, you should have asked me for the other arm and stuck that one!
C.) Next time please release the tourniquet BEFORE removing the needle…as you learned quickly this causes blood to come flying out of my arm!!
D.) Don’t act like you didn’t just mess up, and I am over reacting for letting out a little gasp!
E.) You should have kept your confidence in what needle you were sticking me with. Switching to a butterfly after messing up the first straight stick….maybe we should have thought about that a little more.
She seemed too scatter brained for me and will never let her draw me again!
Needless to say my arm from my elbow to my shoulder is in a lot of pain and I don’t think this lady should be able to draw anyone else’s blood until some further training is given to her.
I’m the fraidy cat patient with all the tattoos. I just want to explain a little: tattoos and shots are stuff going IN. Not scary. Blood coming out is scary.
Also, maybe I’ve never had a good phlebotomist, but I have been told every single time, my veins are tiny, they sit right on the tendon in my arm so they roll, they won’t come up like they should etc. I had my first blown vein yesterday. The nurse said I was too dehydrated to get blood from… Which I would believe except I’m definitely not dehydrated.
Contrast that with sitting in the tattoo chair talking and laughing and the tattoo guy telling me my skin us great for tattoos or how cool the design is.
One of those is horrible, the other is not.
And, to be fair, yes I know it’s weird to love tattoos and almost faint every time I get a finger stick iron test. Phobias are weird.
This is a great post. I wish all medical professionals would read it.
Excellent tips…as a C.T. tech I start I.V.s for contrast injections.
I am always looking to improve my technique.
Any other sites you recommend?
Thanks…Mike
I know it’s years old, and surely she will not read this comment…
Nancy Nurse: I have tattoos. They hurt. I sit for hours on end in pain and anger towards my artist, however, when they are finished I have a beautiful piece of art to last me a life time. When you are done poking me with your needle? I have a bruise and an arrogant comment about “Oh, you have tattoos so you obviously can’t feel pain.” You are an idiot.
Aside from that, I am glad to read people in the industry are aware of these things. I had a nurse taking blood once tell me I was “rolling”, I had assumed she meant “rolling along” and when she leaned back we were done, only to discover she was blaming me for her inability to hit the vein.
Having served in the military, I have initiated a few IVs, and it isn’t the easiest or predictable task, but that doesn’t mean you have to defend your mistakes by attacking the patient.
I am a patient that gets IV vitamins every week. I have heard everything that you have listed above about “what not to say to a patient” out of the last 3 weeks I have been stabbed 18 times. 7 times week 1 and no vitamins, 3 times week 2 and got the vitamins, and 8 times week 3 and no vitamins. I have bruses up and down both arms and all over both hands. I drink plenty of fluids before hand so don’t understand why this happens all the time. They always start the IV with the butterfly needles, we have tried running my hands under hot water. I’m told I’m a hard stick, have bad veins, my veins blow all the time…. are there any recommendations that might help me out?
In the past month I unfortunately have had to have an iv inserted 3 times, each time worse than the last. I do not want anyone coming near me with a needle again.
I have had my share of bad experiences, all the while hearing OMG what small veins you have.
My response the next time is going to be, if you don’t feel up to the job, go get someone who won’t blow every vein in my arms and hands, please because it’s just too damn painful. I never used to be so fearful of this procedure, but the last 3 times and 6 blown veins have left me more than shy… what can I do? Unfortunately they are the ones with the big end of the stick (or should I say needle?)
MY 7 yr old went to ER in January. After a 2nd trip to ER they admitted her. Of course, they had to administer an IV to admit. No prob. I explained to her that it would hurt a little(fib) but she was brave.
Nurse stuck, fished a bit, fished some more,and more, and more, then finally said i’m gonna go get someone else to try. DOc asked “r u gonna leave that needle?” “Yes, dont want to have to poke her again” of course thru all this, my little girl is screaming her poor head off!! The nurse then leaves needle dangling out of 7 YR OLD ARM and goes out of room to find another nurse. 2nd nurse tries to fish some more. THen they get a scanner,and find the vein is rolling, and fish some more. After 35 MINUTES I finally had to say she has had enough, she needs a break. They admit to me that while she is crying, the veins will collapse,and be hard to catch. Well, DUH!! we should have stopped 30 minutes ago!
The doc suggested we wait til we get up to pediatrics floor. We got up there, and those nurses had her IV in without incident in 1 1/2 minutes!!!
Needless to say I had a fit in my complaint to the hospital about the bedside manner of the ER nurse.
If u cant get it, admit it, and move on!!
Going back to the subject on touching the site too many times with non serile gloves. I am pretty bad at doing that, when I have to start an I.V. a lot of times my first try is the patients third time getting stuck because I work in an ER so I want to get a good feel for what I am going for because we are running out of chances. That being said, after I have everything out and ready to go I take an extra alcohol swab and while I am taking one last look I wipe down my finger tips. That way if I do end up touching it again I know its at least a little better then touching it with who knows what on your gloves. I’m not saying that is the right way to go about it everytime but it at least is a little better if you do end up taking one last little poke and prod when things are going down hill…
I started doing I.V.’s about three years ago, and have become very good at it. This is because I had to overcome many challenges. Although I can go months withouth missing one stick I do have my days when I just cant get it on the first time. Best advice I could give is ask the patient if they have a preference in which arm you stick. The patient knows best, and they know where they normally get drawn. As a patient I would never tell the medical person that you are a hard stick because your putting it in their head that it will be hard, and they second guess themselves. I think typically you can only try three times and your done. Atleast that is my policy at work. Im sure its different in emergency situations
Wow am I ever even more thankful for my nice, large, stable veins. I may have had a “bad stick” when I was unconscious (I used to crash motorcycles a fair bit) but I’ve never had someone have a problem sticking me that I’ve noticed. Although, I have the most amazing rolling vein on the back of one hand, I can make it wiggle back and forth by moving my fingers, it’s that cool! I first noticed it when I was about 15, so rolling veins are not just for old people!
For elderly on blood thinners or very frail, easily blowable veins- try using your b/p cuff instead of tourniquet, pumped up to about 60-80mm. It’s enough pressure to get the vein firm, but not enough to blow it.
@Steve, thanks for these tips they’re very helpful, i don’t know if this was mentioned in another part of this website, but one thing i learned early on(and i hope i’m not making myself look like an idiot right now) before you flush a vein or run fluid and ALWAYS before you push D50, pull back and make sure you have blood return. Doing this ensures a patent IV line and avoids the swelling and pain of saline in the subcu space (and tissue death from D50).
Steve, I JUST had this happen to me today. Was having an MRI with contrast, the tech missed the stick to run the dye in on the first try, and asked me if my veins ever blow! Totally made me feel like it was my fault. There is so much wrong with our health care system; more guys like you should be training people! Keep up the good advice.
I do have a question for all the nurses out there performing IV’s? Why don’t you ever listen to the patient?? We know our bodies best and some of us have had IV’s several times (including myself), and know where a vein can be found. But I swear at times it’s some sick challenge for nurses to get the vein they pick. I have had them dig, pump my hand, blow out veins, made me pass out, and left horrific bruising. Here’s a thought, it’s not digging for gold. If you can not find it perhaps listen to the patient when we say something like “I have always had good luck in my hand”.. Hence the fifty poke marks. Just listen, then maybe the patient would not have to go through unnecessary pain.
@ Janet…Try not to generalize so much…There are great nurses, paramedics, EMTs out there that DO listen to our patients about their bodies. Unfortunately, the vein that was good yesterday may not be as good as another today…AND I assure you that most nurses don’t see finding a vein as a “sick challenge.” As a patient, it is always your right to ask someone to stop what they are doing or ask for someone else. So next time that you have an issue, do that instead of posting generalized, negative statements on a website that is intended to help professionals become better.
I want to add one.
Stop going straight for AC’s. Remember what you were taught in EMT – I or Paramedic class. Start Distal and work Proximal.
It agrivates me when somone ask for my advice on where to stick after missing or blowing an AC and the pt had ropes all below that site. Unless its a truama then by all means AC away
I’ve been starting IV’s for over 30 yrs working at a busy metro ambulance service. In my experience, hand pumping and “flicking” the vein with my finger works well.
In any event, very nice website. I’ve enjoyed my time here and will be back on a regular basis.
Thanks for your website. It is great to share tips. I’ve been starting IV’s for about 25 years and it is always good to continue to improve. I agree with Duke, hand pumping and flicking the vein does help sometimes. I wouldn’t do those things on a routine basis. I loved reading ‘don’t blame the patients’ when the IV doesn’t go in the first time. That is rude! Even if it were true, not a nice thing to say! My addition, if I had a vein blow, I have had success not using a tourniquet on the second try, if you see a good vein. I do respectfully disagree on picking the site within 12 seconds. Probably that is necessary in emergency ambulance scenarios. If you are in the hospital setting and no emergency is happening. Take your time and find a good vein. This makes a huge difference. I have a good first stick success rate with carefully finding a good vein.