Incident or not? - page 2
So tell me what you think about this. I need advice, I was a witness to what might be considered an "incident" tell me if you think it is or what you would have done. Patient comes for ER, has a... Read More
Oct 14, '05Quote from siriIs it an incident? Yes.
Is it a med error? Yes.
Was the patient harmed? Yes.
Question is.......did the patient develop sequlae from the room air?
You are tough woman....The patient's sats drop as you would expected due to the wrong port. After given the correct port the sats increased again. Therefore, was the patient harm...yes in the sense of no o2 and sats decrease however no brain damage.
Secondly, o2 is a medication and again wrong port....medication error yes.
Thirdly.....can you write a med error and incident together?
Please explain to me why a discussion about the incident to those involve could not take place of all of the two infarctions?
Ears are wide open.....
Oct 14, '05Quote from NurCrystal22[FONT=Franklin Gothic Medium]Someone help me on this....room air is approxamately 21% O2. O2 per nasal cannula at 2 lpm is what? 30-35%. at the max, if the patient isn't moving and consuming O's and leaving it on in both nares.(we've all seen the cannula in the cheek method) :imbar The patient may have co- incidentally dropped his 02 sat (playing devils advocate) were you sure the Sat was accurate ? There are many reasons that a SAT drops. A sat is a guideline figure or a guage to help us be aware of changes in the paitents condition hopefully sooner...a tool. ( I have seen the most beautiful V-Tach by a patient vigorously brushing his teeth) Renal patients are notoriously anemic and recieve EPO or the like to assist in their chronic anemia. That will also decrease the accuracy as it measures color penitration (saturation) thru the nail...low h/h =inaccurate SAT. (dark or any nail polish will do the same) Also MEDICAL AIR is in most emergency departments as most if not all VENTS cannot function without medical air. Most ED MD's also, for severe COPD patients, will order their nebs on medical air. Because in recieving continous nebs the patient can cease to breathe by raising their PaO2 when too much O2 is used (the O2 / CO2 drive stuff). S[FONT=Franklin Gothic Medium]o they recieve their back to back nebs with medical air and prevent danger of shutting down their drive to breathe . Incident......well....okay, but really as seeing the response about medical air. and how many people did not know how and why it's there.....one would hope it to be a learning experence!So tell me what you think about this. I need advice, I was a witness to what might be considered an "incident" tell me if you think it is or what you would have done.
Patient comes for ER, has a history of CHF, ARF, he's diabetic and his chief complaint was chest pain. He's suppose to be on 2L of O2 but somehow he got hooked up to the "room air" port... thus his 02 sat dropped to 83-87 so we called the doctor, he flips out orders a bunch of labs and wants him transfered to ICU, AFTER we call we go a notice that he's connected to the wrong port, change it over and he's back to 95% so we call the doctor back and he says fine and cancels all the orders. NOW, would you say harm was done to the patient?
Oct 15, '05Yes, it is an incident, but no I wouldn't write it up. I would leave that to the nurse who did it. She is responsible for her own mistakes, and I would file this one under NOMB (none of my business). If the patient had been harmed... well I'd have to rethink.
Oct 15, '05In my facility this happens more often than I'd like to admit because the ports look very similar and are right beside each other (O2 is white/green, medical air is white) and of course, staff being in a rush to hook them up.
The hospital I work at requires us by policy to write up these incidents as to prevent the same errors from happening again in the future. If enough are reported, perhaps the safety committee will act on it, by changing the color of the ports to something totally different, or by making the outlets not fit properly in the wrong port.
We don't write them up to report our mistakes, the purpose of an incident report is to help instigate change to prevent similar things from happening again.
Oct 15, '05O2 sats temporarily dropping to 87% is causing patient harm? That happens to many patients when they eat lunch. I'm inclined to disagree. What's more, having the two ports side by side is a potential accident waiting to happen. I would think that it would be inevitable that someone would make that mistake eventually, especially if they aren't clearly identified and especially if the unlucky person were new to the unit.
Oct 15, '05An incident report should not be thought of as punitive - it is a LEARNING and CORRECTION tool - it doesnt just affect the nurse, it affects the way systems are handled all the way down the line - even up to the manufacturuers of these ports....
It *IS* an incident report so that corrective action can be taken, and pertinent data can be gathered - NOT to punish the fellow nurse! Yes that patient's nurse should write it up, not the fellow nurse who observed it. Afterall, she is covering herself by taking a corrective approach which not only takes ownership and accountability foe the problem but of the SOLUTION! What if it happens again, and then someone says "But nothing happed when HE did it before!" The problem is just allowed to continue!Last edit by gauge14iv on Oct 15, '05
Oct 15, '05An incident report should not necessarily be used to punish anyone. In the facility where I work incident reports are utilized to prevent future incidents that might harm patients/visitors/staff. If after thinking about what happened, can you file this incident report as a patient advocate? Will you be preventing future patients from being harmed? Can you talk to the nurse who made the mistake and help that person to find a solution to keeping this from easily happening again? If your facility encourages staff to help in fixing problems, writing incident reports becomes much easier.
Oct 15, '05Quote from sagarcia210:yeahthat: EXACTLYYes, it is an incident, and could be considered a med error also. Oxygen is considered a medication in some places because it has to be ordered and it is essential to the patient's well-being.
Because it could have caused serious harm to the patient, it would have been a class-II sentinel event at the hospital where I work.
Oct 15, '05We don't have air ports in our ER either . .. . I had never heard of them.
Let the person who hooked them up to the wrong port write the report - this needs to be ferrated out to solve the problem.
And I agree with no harm . . . .our patient's sats do drop just doing things like eating lunch or walking to the bathroom.
Oct 15, '05I must still say this patient was harmed. He arrived in the ER for chest pain warranting treatment of which O2 is essential.