Aftermath of Liver Transplant Donor Unexpected Death

  1. Positively Moving Forward
    http://community.nursingspectrum.com...e.cfm?AID=7360

    This article talks about the unexpected death of Liver Transplant Donor that happened in the liver transplant unit this past January at The Mount Sinai Hospital in New York City

    FRom the Director of the unit:

    "We have added nursing staff to the units to help with communication and patient evaluation. We now have a 4 to 1 RN-to-patient ratio. We have also replaced first-year medical resident onsite coverage on the transplant unit with nurse practitioners and physician assistants to enhance response times to pages and to promote continuity of care and communication"

    Lack of effective communication was determined to be the root cause leading to patients death.
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  2. 12 Comments

  3. by   oramar
    I still feel terrible for the victims of this incident. However, I am glad they are looking at things and have made such radical improvements. The thing that makes me sad is that I know that they were warned by nurses that things were getting bad and that someone was going to get hurt. I will bet my house that managers turned a deaf ear to the warnings. How do I know? Because there were no experienced staff on that unit. Which can only mean that experienced nurses fled because they were fearful of mistakes and no one would listen to them. I have a sick feeling in my stomach because right now all over this country there are nurses warning managment of conditions that will endanger patients. You can be sure they are being given the brush off.
  4. by   -jt
    <FRom the Director of the unit:

    "We have added nursing staff to the units to help with communication and patient evaluation. We now have a 4 to 1 RN-to-patient ratio.>


    Gee....... I notice that the director didnt mention that the RNs were previously assigned 7 of these pts each & had been protesting with picketing that hospital for a year over their staffing & RN : PT loads - & the hospital did nothing - except lay off assistive personnel. And she doesnt mention that even AFTER the death hit the news, the hospital went ahead with more layoffs & even eliminated vacant RN positions. While the hospital was being fined by the state for poor staffing that lead to this death, and the news was all over it, it STILL did nothing about staffing. The RNs had to continue to picket the hospital & even threaten a strike before it would improve staffing. And she doesnt mention that similar units as this in other hospitals here have a 1:1 pt ratio.
  5. by   -jt
    <You can be sure they are being given the brush off.>

    Of course... and then the RNs will leave the job.... and the hospitals can say there are no RNs to be found for those positions. "so what can we do??? We MUST provide some kind of staff, so we'll just have to hire less expensive UAPs to care for the pts instead of spending what it will take to make the job one that RNs will work in again".

    Perfect excuse to cut costs: Run the RNs off & then tell the public they cant find any RNs. Justifies giving more responsibilities to the less costly UAPs & the public just might accept that because, hey, somebody has to care for those pts. "And there are no RNs."......

    .......who are willing to work in these conditions - thats the part they alawys forget to say)
  6. by   rncountry
    I thought the same thing about the staff ratio's Julie. 4:1 is still too high. Though I have no experience with transplants and neither the hospital I work at nor the host hospital does them, common sense tells me that is still a ratio that is pushing the limits severely.
  7. by   -jt
    I worked agency in UCLA in the liver transplant ICU not too long ago. There were 11 pts, 9 RNs & 3 CNAs. I thankfully was the one who got the only 2 stable pts. The rest were all 1:1 but for all 12 hrs at least 3 RNs were together at one bedside or another.
  8. by   rncountry
    Julie I surely wish I had been able to meet you while in Washington last year. My mind has been expanding and maturing, learning more things. I have belatedly found some of the people I was networking with were, well, a bit off. When I objected to some behavior that I felt was less than professional I about got me head bit off, not to mention being told I was a sellout, and possibly I was mentally ill. All I had requested is that the person who had been sending me copies of emails that were being sent to some state associations and boards be professional in tone instead of strident and sounding like an ill educated just pissed off person had written them. I put it a bit nicer than that but that was the drift. Felt like I had suddenly been thrown into a communist re-education camp with the response I got back. Because I have opted to work with the democratic party here in Michigan in an attempt to educate and get some needed legislation, what bit I can contribute to this, I was told I was simply a management type who was doing nothing for nursing. So ok, whatever. I have spent the last couple months talking and talking to labor people, to others who may be willing to help and actively working on the political campaign for the gal running in my district. It may not be much, but I feel this is the way I need to go. On the 11th, my candidate had a debate with the opposing party at a VFW and while the other candidate talked about terrorism and such, mine talked about how the nursing shortage will impact on the care available should a attack occur with massive casualties, and how the shortage is impacting the "greatest generation" including vets. I spent a great deal of time putting this all together so it made sense to an audience who likely does not think of all this. To know that she received a standing ovation did my heart good. And since the other candidate was busy scribbling notes on what she was saying, I thought perhaps he may take this issue a bit more seriously now too.
    For any rotten ass thing I ever said to you, I apologize.
  9. by   sjoe
    rncountry--Well, now you know that EVERY group has its extremists and true believers, if you hadn't run into the notion earlier. Some people have a major need to feel self-righteous, no matter what the cost--more PC than their neighbor--and they will ALWAYS be involved with something that makes them feel superior. On the other hand, some people have a major need to keep from making any waves and experience those who do as reckless.

    I doubt that basic personality types are likely to decrease in variety as time goes by. (Another good reason for the "ignore" feature on this BB.)

    Somehow our republic just keeps staggering along with many kinds of personalities. At least, so far.
    Last edit by sjoe on Sep 23, '02
  10. by   -jt
    <<When I objected to some behavior that I felt was less than professional I about got me head bit off, not to mention being told I was a sellout, and possibly I was mentally ill.>>

    LOL!!!!!!! Oh man!! Do I know how you feel!!!!!

    But QUIT APOLOGIZING TO ME!! Once was enough. Its past. I never took any of what you said personally anyway. I figured you were just starting out & passionate about what you wanted to do. Cant blame anyone for that. Effective dialogue comes with maturity & experience. We all have to learn & see things for ourselves as we get more involved in something new. Sometimes the passion can spill over & we lash out at others in the heat of the moment. We're only human & sometimes it can be very hard to not respond emotionally. I just forgot about the rotten-ass things & thought that as you went along in your new endeavor & learned more, youd be able to see past the emotion & understand other points too, even if you didnt agree with them. Im a NYer - we have tough skin & no time for anything - not even for holding grudges. Rotten-ass things aside, its good that people can look at things differently & have different opinions because knowledge, understanding, energy, great ideas, & wonderful things happen when they constructively share those different views with each other.

    Im glad I was able to help in some way. You should be very proud of yourself for all youre accomplishing. Make sure your name is included & with the title "RN" on all the press your candidate puts out - especailly when she wins!

    Thank you for your post. If you ever find yourself in NYC, give me a call.

    BTW, I have been getting some of those same email copies too - cant make heads or tails out of them.
    Last edit by -jt on Sep 17, '02
  11. by   -jt
    <I was told I was simply a management type who was doing nothing for nursing. So ok, whatever. >

    EXACTLY! So just say a little prayer for that poor person, delete the mail, smile, & keep on moving on.......
    to bigger & better things.
  12. by   rncountry
    Thank you Julie, very much.
  13. by   -jt
    <while the other candidate talked about terrorism and such, mine talked about how the nursing shortage will impact on the care available should a attack occur with massive casualties, and how the shortage is impacting the "greatest generation" including vets.>

    Speaking of that.......

    this months AJN (sept 2002) has some articles about that kind of thing. You might want to order a copy from Lippincott to give to your candidate. Earmark for her attention page 65 "Correlation Between Staffing and Quality", page 73 " Holding Society and Nursing Together", page 76 "Public Health - One Year Later", page 99 "Policy Perspectives - The Effects of September 11 on Health Policy".

    Article reprints can be ordered by phone: (215) 521-8560
    AJN office - 1-800-933-6525
    ajn@LWW.com
  14. by   oramar
    rncountry, glad to see you still posting, don't hear from you as much as we used to. also glad to see you are still active and involved

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