I took care of a patient who had just had a PICC line placed, spiked a fever the next night after surgery, and went home a few days later. I got an email that her cultures came back positive for a CLABSI. My patient had literally just had the PICC placed a few hours prior and was a few months old. I disconnected the tubing to draw labs, at this hospital the policy is to draw labs from the cap most proximal to the line. When I disconnected the tubing, I didn’t realize that there was no cap on the end of the line. The PICC nurse had connected a J loop directly to the line, then a cap at the end of that, then the IV tubing. So I directly exposed the line to the air and wasn’t sterile. I put a green cap on the line and got sterile and performed a “cap change” aka put a cap on and replaced all the IV tubing. I wasn’t expecting there to be just…no cap on the end of the line. I’m a traveler. I’ve never seen this before but apparently that’s how the PICC nurses set it up because the line is so small, and you draw labs from the cap at the end of the J loop extension piece. The patient got a CLABSI less than 48 hours after the PICC was placed, so I’m 99% sure it’s all my fault. I’ve been a nurse for years and never had a patient of mine get a CLABSI. I’m also ruining the unit’s no CLABSI streak of 3 fucking years. I feel awful. I had been so stressed immediately after it happened and even more stressed when I saw that she got a fever, I felt better seeing she was discharged but nope it really was a CLABSI. I was hoping to go staff here but now I feel like there’s no way they’ll hire me :( Has anyone made a similar mistake? Has anyone seen a PICC line done like this where there is no cap directly on the line?   submitted by   /u/wizmey [link]   [comments]