Need some advice
- 0I work on a Cardiac Stepdown unit. I work nights. My pt went for a PPM insertion. The day nurse had given the pt lovenox, asa, plavix prior to the procedure. After the procedure on my shift the pt bled out. It was a mess. The nurse manager came in the morning, I was not in charge that day but the charge nurse had told my manager what had happened. I had to fill out an incident report. I really did not want to because the patient was stable. Had to give a unit of blood. I felt so bad for the pt. She was such a sweet lady. She just kept saying I'm so grateful to be alive and you're doing such a good job taking care of me (it takes a lot for me to cry and I just started tearing in the room). I don't know why I feel so bad for filling out the incident report. The day nurse was probably busy and just made a mistake (we all make mistakes at one point or another). A lot people complain that she's lazy and is always on her phone but I'm usually the last one to report a person (it has to be life or death with me). I didn't report her just stated facts in the incident report. Any advice, thoughts? Just grateful my pt is ok.
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- 4Mar 9, '12 by HouTx GuideWould it have made a difference if the patient had died? Corrective actions should always focus on the behavior - not the outcome. Although it is tempting, we have to avoid 'grading' incidents based upon the result because that is often the result of luck or chance. The only thing we can change is behavior. Sometimes we need a wake-up call to help us see that taking shortcuts or skipping steps actually does have an impact on patient safety & outcomes. I am sure that the nurse in question will be much more vigilant in medication administration from now on.
Human beings make mistakes and unfortunately, our patients are usually just one human error away from a catastrophe. As health care professionals, we have to step back and realize that we are actually just links in the very complicated process of delivering patient care. We need to build in as many fail-safes as we can (chart checks, co-signing, etc.) but the most important fail-safe is our own diligence. When we catch an error/mistake, that information has a direct impact - either by correcting the problem behavior or improving the system.
- 0Mar 9, '12 by Esme12 Senior ModeratorIt is not your fault she made a mistake. I agree without.....the mistake is the issue not the outcome although I am very glad this patient was ok. To bleed after a PPM insertion enough to be transfused is a potential if not actual sentinel event and reportable to The Joint Commission and possibly the Federal Government.
I understand that you feel bad, but hopefully this will help the nurse learn how to avoid these mistakes in the future or possibly help with systems issues in the facility. It's pretty basic that you don't give anticoagulants before a surgical procedure, so I'm glad the patient is OK. I am also wondering what the coags were that she bleed like that or what bleeder the MD didn't tie off to cause that kind of blood loss. I think there a ton of other factors here as well.
Great job nursing the patient....
- 2You're right! At our facility nurses write each other up for things that are not even worth it (such as not restocking the medication cart with syringes and alcohol pads...the supply room is 2 feet from the nurses station) that I forgot the main reason why we have incident/occurrence reports. Thank you for reminding me.
- 2Mar 9, '12 by turnforthenurseRNQuote from Been there,done thatI agree, however the nurse is still the last person to touch those meds. As Esme stated, it is pretty standard to hold anticoags prior to a surgical procedure. I know on my floor, patients will get a Lovenox in the AM (0800-0900) but the evening dose will be held. By the evening, the physician should discontinue the Lovenox, but they don't always do that. The nurse should have called the physician to clarify.Did the doctor write an order to hold these meds prior to the procedure?
Is there a written protocol to follow for this and other tests/procedures?
If not.. it is the doctor and the unit manager that need to be written up!
OP, you did a great job!
- 0Mar 9, '12 by DixieRedHeadLet's look at the bigger picture. I am sure that the chart went with her. The OR should have questioned the medications that were given.
And yourself. Did you check? As you said it was a number of people. And it's an "incident report" not a snitch sheet. And I don't think you should feel bad at all about filling it out.