Seeking advice (clinical)

[AllyRN82, MSN, APRN]

I'm not exactly sure where to post this, but I am a traveler, so I thought it'd be appropriate here. It doesn't relate to travel nursing specifically, so I understand if it gets moved.

I had a pt with several complications from a spinal surgery a few years ago. This pt has had several years of uncontrolled pain. This pt was admitted requiring vent (this pt is trached) assistance. The narcotics this pt was receiving at home were quite the heavy doses. When this pt was admitted, those meds were stopped. This pt ultimately began to withdrawal requiring more time in the ICU on the vent. The narcotics were slowly reintroduced. This pt turned out to be very sensitive to narcotics, and would become apneic as a result during vent weans. The pain was still a huge issue, but a tricky one because of this pt's response to narcs. One step toward better pain control was the fentanyl patch was increased. When the nurse who applied the patch scanned it, they were prompted to select a time for it to be removed, which is typically 72 hours, but this nurse accidentally checked 12 hours. When I came on that night, I had noticed this pt's PRN pain meds had also been increased. When I got the alert from the eMAR system to remove the fentanyl patch, I did. It wasn't something I just did because a computer told me. I thought it very strange, and went through the thought process in my head: "ok. This patch was just increased today, but so were the PRN meds. Maybe they really only wanted to increase the patch for 12 hours and try again tomorrow." Without giving away too many details, this pt's body weight is not very high. It seemed like a reasonable thing, so I felt ok about removing said patch. I did give frequent pain meds later that night, but it wasn't anything too unusual for the pt and the poor pain management that was already present.

Apparently, the pt went 3 days without a patch, as it didn't alert the following nurses until it was due again. With this pt requiring increased pain medication, the MDs increased the patch again. Correct, the patch was not on to increase a dose from. That nurse realized that when they went to apply the increased dose and remove the old one (that I had taken off 3 days before).

I am called later basically being given all the blame for this incident, that I should have put more thought and critical thinking into that situation before removing the patch. That I should have spoken with the MDs about what the new pain plan was after removing the patch. I assumed increasing her PRN meds and trialing the patch dose was the plan, so I didn't question.

The blame is being put all on me, and I'm not ok with that. I will take my part in this, but to tell me I didn't think it through was insulting. I was tried to be frightened into just how horrible my act was: "if that nurse had put that increased dose patch on that pt, it could have been fatal." Yes, I accept responsibility for it, but please don't bully me about it, and it wasn't all just me. Plus, as a nurse, during my assessment, I look everywhere for patches, even if they're not ordered for one- I scan their bodies looking for one, along with my skin assessment. It was evident the following nurses don't make that part of their assessment, and I think it's a very important part of an assessment.

There was another incident not but a week before this. Pt was bradying down, dropping pressures, losing consciousness, basically precoding. I ran in to help the nurse, was handed an amp (out of the box, ready to go) was told it was atropine and to give it. The pt's hr was dropping dropping dropping 20s. I pushed half and waited, nothing was happening, so I pushed half again. Pressures shoot to 200s, hr 170s. Turns out I had pushed epi. Again, all the blame was put on me. I completely accept responsibility for my part in it, but I was also handed a vial from the nurse being told it was atropine. I understand I'm the ultimate last check, but in precode/code situations, I don't do that when someone is handing me meds that are vital to being given. I will no longer trust that someone is giving me the right drug in those situations, and it's made me even more vigilant than I was before. The pt wasn't harmed, and it was a huge lesson for me. But I don't feel all the blame should be placed on me.

As a traveler, you all know our voices are rarely heard. It's near impossible to defend yourself against their loyal staff of 20+ years. Does anyone have any suggestions on how I handle this? These are resulting in "important meetings" that I have to be a part of, by myself. I truly have accepted my responsibility in all of these incidents, and have learned valuable lessons, but I don't know if I can stomach a verbal lashing when I wasn't the sole offender.

Thank you so much for listening. I know this is long. I hope everyone has a great day :)

[txmed/surgRN]

My first thought was "did you check the doctor's order before removing the patch?" since it is unusual for a patch to come off in 12 hours. With the pushed med, was it pre-filled syringe or did the other nurse pull it up? I NEVER give a medication that another nurse has drawn up or pulled out of a package, for just that reason.

The other people involved in these situations may have received similar "lashings" that you speak about. it is difficult to know because discipline is generally done in private. You may feel that you received all the blame, but in truth, that may not be the case.