Jokes on me....?

  1. I've been traveling for almost 2 years now and have gained so much knowledge along the way. Been a nurse since 2007 and its been an honor. Very big accomplishment for a mother of 3. My recent position was in east Columbus on a busy CMICU unit. Patient ratio is 5:1, which I couldn't believe due to patient acuity ( OHS patients, fresh thoracotomies, Ptca, and pacer implants, etc). This particular night I started with 4 patients, a patient awaiting OHS on Heparin drip with a new infection, new onset Afib on a cardizem drip, IVDU with endocarditis/septic emboli going for colonoscopy starting prep and new MI first troponin 5.74. The night was BUSY to say the least, family issues in one room, colon prep already working in another, sleep deprivation in the 3rd and constipation in the last. I had 2 heparin drips, Aptts drawn every 6 hrs, one therapeutic, the other way to high. My new MI needed her drip shut off, my OHS patient was therapeutic. As the night went on I ordered a new bag for my OHS patient. Doing hourly rounding I noticed the OHS room was dark, no glow from the IV pole. Going all the way in the room I found that the bag wasn't hanging, the pump shut off and no connection to the patient. Found the bag and tubing in the trash. Waking the patient up, she reported a guy being in her room dismantling the IV, thats how she was awakened. Coming out to the nurses station, I asked if anyone had been in that room or dismantled the IV. It was met with disbelief from some and laughter from others. It was 3 males working that night, charge being one of them. Not knowing how long it had been off I quickly restarted the bag I ordered and waited for next Aptt to be reported. It was barely therapeutic. I was very upset by this. No excuse can be made for someone's actions. It was deliberate. What can I do moving forward? What are my options? I think light should be shed on this act? Patient safety can be argued. I need help in understanding this. I'm struggling....and ended with a 5th total complete patient before morning. HELP.......
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  2. 27 Comments

  3. by   TriciaJ
    First of all, it's very hard to read through your wall of text. I'm trying to understand what happened. Please spell out your abbreviations once for those of us who might not be familiar with them. We aren't always familiar with each other's abbreviations.

    Are you saying 3 of your coworkers disconnected an important drip on your patient for a prank? Or was there some other rationale? This is a huge patient safety issue and you'll be complicit if you don't speak up.

    My first response would be to write an incident report because it is an incident. Then I'd request a meeting with the nurse manager. Depending on how that goes, I'd consider getting out of that particular contract, if I could. Unless I'm completely misreading your post. Let us know how it turns out.
  4. by   JKL33
    Was anything further said - none of them confessed or offered any explanation? It was a prank and that's the end of it?

    Notify physician. Take steps to rectify the situation according to orders. Document in record (not that there was an "incident" or that you filed an incident report, but that upon entry to room the medication was noted to be disconnected from patient and what steps were taken - including the names of those you notified).

    Use facility's procedure to file incident report, including the patient's report and your findings. Notify house admin (immediately/at time of incident) and your immediate supervisor as soon as possible.

    Leave the contract.

    Consider reporting the facility.
  5. by   dream'n
    You had seen the pump and bag running before this incident. I would have grabbed a supervisor, written an IR, and after my shift never went back to that unit due to safety concerns. I also would have raised **ll.

    The fact that you say a new Heparin bag was ordered by you from pharmacy makes me think that maybe your pump beeped and some idiot just disconnected and trashed your empty Heparin bag without checking what drug it was or even letting you know. And they were too cowardly to fess up.
  6. by   Coffee Nurse
    I'd also take out a good deal of detail from this post so it's less identifiable. You never know who might be reading these forums.
  7. by   Been there,done that
    Report the issue to the facility and the agency. That would be plenty enough for me to quit the assignment.
    You should be able to walk away with the proper documentation, I have done it.
  8. by   Ms.UndastoodRn
    The bag wasn't empty yet. I ordered a new bag because at the rate of drip it would not have lasted until morning. The heparin bag found in the trash still had atleast 30-40mls. Running at 15mls/hr, I still had a few hours left. I ordered a new bag around midnight after a rounding check. By 2 am it was completely off and disconnected in the trash!
  9. by   Ms.UndastoodRn
    I honestly had the name of the facility at first. I felt pretty inflamed by the incident. I'd been there 12 weeks, received references for my next job from my coworkers. Always early and ready for whatever. Never complained and took admissions, transfers and pulls without question......
  10. by   cleback
    Are you saying something took it off as a prank?

    You also had two patients on heparin gtts, and the other patient's was being discontinued. Is it possible that someone-- you or a coworker-- made a mistake by turning the wrong one off?

    Maybe I'm being overly trusting, but I'd say the latter is more likely than the former. Anyway, write an incident report and hopefully the cause will be determined so it doesn't happen again.
  11. by   TriciaJ
    Quote from cleback
    Are you saying something took it off as a prank?

    You also had two patients on heparin gtts, and the other patient's was being discontinued. Is it possible that someone-- you or a coworker-- made a mistake by turning the wrong one off?

    Maybe I'm being overly trusting, but I'd say the latter is more likely than the former. Anyway, write an incident report and hopefully the cause will be determined so it doesn't happen again.
    That was the next thing I started wondering about. Was there heparin (or whatever it was) still running on another patient where it was supposed to be discontinued? That would make 2 incident reports.
  12. by   Ms.UndastoodRn
    I'm not really saying anything. No one would "confess" or own up to the "mistake". The heparin was off my other patient per Dr's order and a schedule recheck was ordered for that patient. There's no excuse for someone to go in another nurses' room and dismantle and throw away a drip. My opinion though.....
  13. by   Ms.UndastoodRn
    I notified charge at the time of the incident. Dayshift charge that morning. Reported it to the manager that morning. Left the assignment a week early due to the agency rep feeling it was in the best interest and a investigation was pending.
  14. by   cleback
    Quote from Tonya36rn
    I'm not really saying anything. No one would "confess" or own up to the "mistake". The heparin was off my other patient per Dr's order and a schedule recheck was ordered for that patient. There's no excuse for someone to go in another nurses' room and dismantle and throw away a drip. My opinion though.....
    I hope that when you reported it to the manager, that you reported only the facts. Here, it definitely sounds like you're insinuating it was a prank. That's a pretty big allegation. After all, those actions would be criminal behavior.

    In a nutshell, if you're unsure of what happened, don't insinuate otherwise. That's just to protect your own professional reputation.

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