Patient Safety: We could be the killer!

[Mayjor Wong]

It took me a while to come back to writing after a nap that rested my mind that exhausted for the entire busy and hectic week that I have had. I have been thinking for the entire night about thing I have learned after the event that encountered yesterday in relation to the issue of 'Patient Safety'.

I had a trembling and shocking day yesterday where I witnessed myself how my colleague delivered a shock to my client with a stable rhythm unintentionally when performing the device system check. This result my client's heart rhythm deteriorated to a life threatening rhythm 'Ventricular Tachycardiac', although it was still in a perfusing rhythm at that time but his hemodynamic compromised significantly. I would say 'defibrillator' supposes is considering a life saving device. Somehow it could be a device that can jeopardize and lead to fatal if we use it inappropriately. Luckily, we are able to revive and salvage our client after the electrical and chemical cardioversion.

Well, as I said the medical equipment can be a life saving device and it could be a device that leads to lethal. This is evidence in the available data that reported the incidence of 0-6% IABP rupture and cause helium gas or air emboli. In other hand, data also demonstrated that the incidence of pulmonary ischemia, infarct and rupture due to inappropriate placement of Pulmonary Artery Catheter is significantly low where account for 0.2% of probability, however, it is associated with high mortality rate up to 50% if it happened. I would say, sometime the 'tragedy' can be avoided if we uphold the significant knowledge, understanding and skill how to handle the equipment in the right manner. Somehow, most of the time, lots of people still neglected the crucial facts and information which might lead to life of others being jeopardize.

However, my prediction telling me that it changed the entire plan and management for the client significantly because of this event. This was because our primary ICU team physician thought that the client is not doing well with the weaning and condition turned back.

According to the initial strategy and management that planned in 24 hours ahead and during morning ICU round immediately prior the event, the client suppose will proceed with the ECMO explantation in Cardiac OT which arranged by CTVS registrar on call and primary consultant. However, because of the VT event, the plan for explant was change instantly and decided to perform ICU instead as the entire team thought that the client was not stable enough transport to OT. Somehow, the plan for explantation is abandoned as claimed to have family issue of concerned. Well, this could be my assumption, may be there is other reason behind to change their plan that lead them to decide explant in ICU.

During and after the event, I did approach the colleague that involved and talk to her about her action that lead to patient's rhythm being compromised. I understand how she feels, her feeling of fear at that moment and I could forgive her action that lead to patient's life being jeopardize and perhaps can be fatal because I knew that was unintentionally and subconsciously. Somehow, I feel very disappointed and I don't think I can forgive her where she attempted to destroy the evidence of rhythm strip that printed from the defibrillator while I was rushed to get Amiodarone from our unit Omicel medication system.

My dear colleague, frankly speaking I do not have the intention to test your honesty and integrity? But don't try to make fool of me as you still haven't reach that stage. Although you have destroyed the evidence, somehow I still can retrieve back the evidence if I wanted to. Although the defibrillator do not have the data storage card, however, it is equipped with the internal event summary that can store up to 300 events and up to 50 6 seconds strip.

Again, It is not my intention to lower your self-esteem and demoralized you from this event. I know if I forward this issue to the higher authority and management level and you will in the great trouble. Somehow I sincerely hope that you can perform your self reflection and have the self-conscious to learn from this incidence, take this incidence as your learning point and do not repeat it again.

Life is full of choices and you can choose not to learn from this incidence. It is your personal choice, somehow, I sincerely hope that you will learn from it and be more vigilant at work and try not to put your client in life danger. Most importantly uphold the 'safe practice' as simple as that.

[PatricParamedic]

I appreciate that this author at least chose to reveal the incident to this Web-Group. Hopefully, after seeing the collective response, he or she has already done the right thing and reported to those who ought to have learned about it in the first place.

Unfortunately, the writer underscores, at least to me, two major flaws in our health care system. Individually, he or she somehow managed to go all the way through a nursing program, graduate, pass state boards, yet STILL ignore some pretty basic principles when good judgment was needed most.

And then there's the more ominous picture - It isn't "We could be the Killer." At 300+ medical error-deaths every day of the year, we ARE the killer.

And the author of this story has proven why.

[CABRN55]

Not much I can add to what has already been said above. I find it shocking (no pun intended) that a defibrillator check was being made using a machine that was attached to an actual patient a "sentinel event" at the very least, as my first objection to the writer's decision to keep knowledge privy to herself, the offender, and the anonymity of this forum, instead of going immediately to her supervisor or safety officer and filing a sentinel event report right then and there. This was a potential criminal act, not just a whoopsy. I have been in health care for 40 years and I've never even heard of anyone ever doing such a thing in my life. I would want this thoroughly investigated as soon as possible because I just have a hard time believing someone would do this accidently, or am I just over reacting? Could someone actually be licensed and be this stupid?

As for the writer herself, I just have this to say. You are as guilty as the offender for not reporting what you saw. It's okay to give the offender a chance to give themself up with you at their side. I've done that myself and been thanked by the offender for standing by to lend support for them to be honest. But not to tell anyone, then write this and hold it up as some kind of threat makes me sick, what kind of person are you, really. I sure wouldn't want to work with you or have you for my nurse. I've worked with your kind and your passive aggressive behaviors make your coworkers hate to come to work. Dealing with nurses like you is worse than any cranky patient or any vile smell or sight we have to deal with. Those things can be treated usually with kindness or medication or just with soap and water, but people like you we have to work with are job killers. You slowly kill the joy and the kindness, the trust and friendship, that binds a unit and kills the bond that is essential to well run unit and kills the need to work for any unit. YOU ARE THE REASON for much of the turnover on so many nursing units in so many hospitals in so many cities where there are so many good RN's. After 40 years I'm glad I finally have the chance to formally write how I feel about the kind of nurse who would write a piece of garbage like what you wrote.

[col3]

It is your professional DUTY to report this- Do you not remember your nursing ethics????. To do so does not indicate that you seek humiliation or punishment for your colleague, but rather, will stimulate action to educate staff on correct equipment use. I agree with the above post- I would not like you as my nurse- in fact i would go as far as to say your errors outweigh your colleagues and i would question your honesty and integrity. And WHY was a test being done on a patient?

1. You were with her/him- it is YOUR error too.

2. You failed to advocate for your patient

3. you failed to report or document an extremely serious error

4. you are not acting as a professional.

Get a copy of the error, report it now before someone dies!