Am I in big trouble?

  1. 0 Long story short: Had a patient who was supposed to be getting surgery (both arms are broken). She was NPO. Dietary brought up a tray for her. I gave the patient the tray and helped her have a few bites. I totally had forgotten that she was NPO!

    Needless to say, surgery was cancel and the RN was ticked at me (I'm a PCA). My unit has a habit of informing the nurse manager every little mistake I make (as well as everyone else's). Well this one was a big one. Should I email the nurse manager of my error before the RN does? Or wait to see what happens?
  2. Visit  ThePrincessBride profile page

    About ThePrincessBride, BSN, RN

    ThePrincessBride has '<1 RN, 3 tech' year(s) of experience and specializes in 'Med-Surg'. From 'Somewhere'; Joined Jun '10; Posts: 1,557; Likes: 3,230.

    12 Comments so far...

  3. Visit  GrnTea profile page
    6
    Fess up.
    And maybe you could spearhead a project to make sure all personnel know when someone is NPO-- a sign n the door or over the bed, perhaps. And find out why she got a tray when dietary should have gotten the NPPO order.
  4. Visit  xoemmylouox profile page
    0
    I agree. You should come up with a way to keep this from happening again. This will help your case
  5. Visit  julz68 profile page
    1
    We have laminate signs that say NPO that are put on the patient door. Dietary sees the sign and does not deliver the tray. Works well on our floor.
    aflower1325 likes this.
  6. Visit  SaoirseRN profile page
    0
    Part of our pre-op checklist includes posting an NPO sign above the beds. Even if nursing forgot
    to cancel the meal trays, dietary will not deliver a tray if an NPO sign is up. This also serves as a heads-up to anyone entering the room who doesn't know that the patient is NPO.

    I would suggest emailing your manager and maybe suggesting this as a way to avoid similar errors for everyone in the future.
  7. Visit  Roseyposey profile page
    0
    This is definitely a system-level problem. I would take the advice given here and not only talk to your manager about it, but bring a couple of ideas on how to prevent this from happening in the future.
  8. Visit  sharpeimom profile page
    0
    I agree with mentioning it first and presenting alternative ideas.

    One of my peeves when I worked in Orthopedics was that sometimes family members would sometimes either not know what NPO meant, despite an explanation, or wouldn't realize the patient couldn't have liquids as well. They'd think it was only foods.
  9. Visit  loriangel14 profile page
    0
    It was not totally your fault. Why did dietary bring a tray to an NPO patient? Where I work they get cancelled.If this is not being done they should implement such a system.

    Yes fess up and hope for the best. It was a mistake but fortunately it didn't cause any real harm.
  10. Visit  ThePrincessBride profile page
    0
    Hey everyone,

    Thanks for the replies. There was a sign on the door, but the door was open and I walked right pass it. I was in a rush and I admit that I should have been paying closer attention. I will definitely look into adding more NPO signs (above the bed) and also having dietary not bring up trays.
  11. Visit  hodgieRN profile page
    0
    The nurse should have cancelled the order in the computer so there was no tray available to being with. The nurse was probably ticked because she knew the tray should have be cancelled. In my opinion, part of the fault was with the nurse. There should have been a sign on the door.

    I am not sure if the PCTs on your floor look in the chart, but you should have checked the diet order in the beginning of the shift. If PCTs don't check the chart, then everything must be ok'd by the nurse first.

    You should say something. The hospital is the last place to sit and hope something doesn't get noticed. Plus, the nurse is going to cover her butt at all costs. She's not going to accept any blame for the postponed surgery if she can, so you better state your case before you are left with just defending yourself.
  12. Visit  SaoirseRN profile page
    0
    Quote from ThePrincessBride
    Hey everyone,

    Thanks for the replies. There was a sign on the door, but the door was open and I walked right pass it. I was in a rush and I admit that I should have been paying closer attention. I will definitely look into adding more NPO signs (above the bed) and also having dietary not bring up trays.
    As well, with an above-bed sign, even if a tray wasn't cancelled, dietary should see it and ask before delivering the tray.
  13. Visit  Kandy83 profile page
    0
    Quote from hodgieRN
    The nurse should have cancelled the order in the computer so there was no tray available to being with. The nurse was probably ticked because she knew the tray should have be cancelled. In my opinion, part of the fault was with the nurse. There should have been a sign on the door.

    I am not sure if the PCTs on your floor look in the chart, but you should have checked the diet order in the beginning of the shift. If PCTs don't check the chart, then everything must be ok'd by the nurse first.

    You should say something. The hospital is the last place to sit and hope something doesn't get noticed. Plus, the nurse is going to cover her butt at all costs. She's not going to accept any blame for the postponed surgery if she can, so you better state your case before you are left with just defending yourself.
    not true, doctors may change the client diet more than once in a day. So the nurse is not to blame, the pca should just fess up, we all make mistakes
  14. Visit  hodgieRN profile page
    0
    Quote from f8dagrate
    not true, doctors may change the client diet more than once in a day. So the nurse is not to blame, the pca should just fess up, we all make mistakes
    And the nurse should be aware of the fact the a tray was still ordered on a pt that was npo. I see it all the time...npo is ordered and the doc doesn't d/c the tray. It is the nurses job to cancel the tray if the doc doesn't do it b/c the NPO order supersedes everything else. It falls on the nurse who received the order at that time. If orders are changed all the time during the day, then the nurse is responsible for making sure an order happens or catching the orders that aren't supposed to happen. I still think two are to blame.


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