Nurses negligent in Minnesota - page 2

State Calls Hospital, Nurses Negligent in Patient Death in Minnesota State health officials say a Burnsville hospital and its nurses were negligent in the death of a Prior Lake man who... Read More

  1. by   mattsmom81
    I wanted to pass on this tidbit as I saw this happen to a coworker of mine.....and she was counseled sternly for it (almost lost her job.)

    A patient had to be intubated and placed in my care in ICU following an ortho surgery...because the nurse told the patient's family it was OK to to 'help the patient' with the PCA pump.....

    Well, you can see the problem...the family 'helped him' into respiratory depression which didn't get caught early enough to reverse the acidosis....so he had an overnight tubed ICU stay.

    So....make sure, medsurg nurses, that your family members aren't administering the patient controlled analgesia...
    as it IS possible even within parameters to give too much if a liberal lockout and dose is prescribed by the surgeon....

    Gotta wonder if family was in the room here too???? Generally patients will NOT overdo their own dose...as they doze off before they can....in my experience.

    You're right, Linda...the system records this info and saves it til cleared.
  2. by   fiestynurse
    This is not the first time someone has died from a morphine overdose in a hospital. We had a case about 6 years ago, where a patient died from a morphine drip. In this case the pharmacist had mixed the IV bag improperly and the nurse never checked it against the order when hanging it. The guy was getting 10 times as much morphine as prescribed.

    Whenever you use IV morphine, whether it be IV push, continous drip, or PCA pump, there should be safegaurds in place and careful monitoring of the patient. The hospital obviously lacked proper policy and procedure in this case. Processes need to be looked at, rather than individual performance.

    These nurses were set-up!! As in many instances it was an accident waiting to happen.
  3. by   Sleepyeyes
    I'm starting to think malfunctioning PCA===however, an alert nurse or PCT should've picked up on his declining respirations at some point, and administered Narcan or at least stopped the pump to check the syringe contents against the pump history.
    I just had someone on a "usual" postop dose of MSO4 PCA and it was 1/6/0/8, meaning 1 mg/ml, 6 mg dose, 0 bolus, and 8 mg lockout per hour.

    What if someone in PACU set the pump wrong?

    Since the hospital didn't even try to investigate, the pump in question would've been re-used for someone else, thus clearing the history.

    As for "helpful" family members--same thing. You'd think that someone would've noticed the patient's respirations were not what they should be.

    But there's usually more than meets the eye to these things, as NrsKaren suggested.
  4. by   Sleepyeyes
    Originally posted by Sleepyeyes


    But there's usually more than meets the eye to these things, as NrsKaren suggested.
    And how tragic for the family!! For the wife, and baby!

    I've given myself a head's-up over this. It is so valuable to me to be able to share info like this that ultimately improves the care that I give my Pts.
  5. by   NurseDennie
    Originally posted by Sleepyeyes
    As for "helpful" family members--same thing. You'd think that someone would've noticed the patient's respirations were not what they should be.
    I don't know about "helpful" family members. Some of them are too strange to believe. I had one patient whose family thought the whole thing was **FUNNY** when I started bagging the guy. Duhhhhh

    Love

    Dennie

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