Epinephrine Error - Broken Heart Syndrome, Part 1

1 hour ago, RobbiRN said:

When you took over as the CEO of Sarnia Shores Healthcare, I was hopeful that we would find ways to increase our efficiency. Some of the initiatives have been helpful. You will likely remember that I strongly opposed the directive to move from a triage system to a direct bedding approach in which no patient waits if a room is available regardless of patient acuity. At the time of the incident, every room in our main area was occupied, and two rescue units were waiting to off-load new arrivals. Twelve of the patients occupying our main rooms had minor or chronic conditions. Ten of those twelve patients had arrived in the hour preceding the incident. Under our previous system, some of those patients would have waited in the lobby for a Faster Care room to open. The twelve patients who did not need acute care will likely increase our satisfaction scores, but their placement in those rooms removed immediate access to limited resources from those whose lives were on the line.

 

This is how it is.

I sincerely hope the writer actually wrote all of those things.

If this is real, etc., I am sorry and hope everyone is okay.

"You will likely remember that I strongly opposed the directive to move from a triage system to a direct bedding approach in which no patient waits if a room is available regardless of patient acuity."

 Sounds like the system was set up to fail the nurse. When staff that uses the system are not consulted, the chances for error multiply rapidly. Hopefully the CEO looked at changing the system and not just blame the nurse!

What an awful situation for the patient and the nurse. I can only imagine how difficult this has been for everyone. If the CEO's first response was to actually ask how they could have such an incompetent nurse working in the emergency department, without having all the information, that's the sign of an administrator that really has no understanding of their own staffing, and no compassion for staff. Unfortunately, there would be so many scapegoats at every level that this will never get up to the people responsible for setting up such an awful system. It's all about those stupid survey scores, not providing the best medical treatment.

I'm just here to add that I think it's fantastic that this letter suggests the manager/supervisor is supporting the nurse and calling out administrative demands that sound as though they were broken from the beginning. Unfortunately, not all units support their nurses when a sentinel event like that happens.

This whole thing makes me so sick to my stomach. If errors like that can happen to the very best of nurses who are in bad circumstances, what hope is there for the rest of us? I really appreciated that the author defended the nurse's well-established credibility and acknowledged how traumatizing an error can be for the nurse who committed it. Those nurses need empathy and support, not punitive judgement.

Also, it's so important to hold upper management accountable for their demands and demonstrate why certain staffing practices are unsafe. I really appreciated the part where the author (respectfully) stated, "Remember back when I told you this staffing expectation was a really bad idea? Here's why." ...Aww snap.

 Kudos to the author for standing up for his/her employees.

 

Edited Oct 25 by adventure_rn

We are all so fallible.  Nurses, administrators, etc. 

I pray for Michelle, Cheyenne, and everyone else to receive comfort, healing, and the courage to carry on. 

I pray for nurses who will stand up and speak up when those who are not working in direct care try to force improper procedures and policies upon them.

As we see from this very sad article, the workers who are actually working on the front line must be involved in making the rules.

Those who won't  speak up could be the next to be caught in the downward spiral.

12 hours ago, JKL33 said:

This is how it is.

I sincerely hope the writer actually wrote all of those things.

If this is real, etc., I am sorry and hope everyone is okay.

 

It is very real and close to home. The writer did write all those things. Everyone is not okay. But, there is still hope for healing. Stay tuned for part two.

6 hours ago, spotangel said:

"You will likely remember that I strongly opposed the directive to move from a triage system to a direct bedding approach in which no patient waits if a room is available regardless of patient acuity."

 Sounds like the system was set up to fail the nurse. When staff that uses the system are not consulted, the chances for error multiply rapidly. Hopefully the CEO looked at changing the system and not just blame the nurse!

So far, the system remains firmly entrenched.

I pray that everyone involved be ok! Many lessons learnt here and the most important one is nurses on the floor to be directly involved in decision making as they know and have seen what works and what doesn't.

Root cause analysis. This is why I try to scan everything that I can.

 

Technically you could push epi for an allergic reaction but not ideal and it was the wrong concentration anyway. Most of the paramedic protocols have pulled it. We also could start epi drips for anaphylaxis but usually they have them ordered for cardiac reasons under the wrong order set. 

7 hours ago, applesxoranges said:

Technically you could push epi for an allergic reaction but not ideal and it was the wrong concentration anyway. Most of the paramedic protocols have pulled it. We also could start epi drips for anaphylaxis but usually they have them ordered for cardiac reasons under the wrong order set. 

I think it's best to start with the idea that we only give Epinephrine IV push during a resuscitation, and seriously question pushing it in any other setting. The recommended IV dose for refractory anaphylactic shock is 0.1 mg over 5 minutes = ultra slow push. In Cheyenne's case 0.3 mg was pushed in less than 5 seconds. 

The last anaphylactic shock that I worked was given two, 0.3 mg IV doses of 1:10,000 epinephrine. It saved her life from a wasp sting, her epi-pen had no effect on the reaction. The patient was in her 40s, and she had no ill effects from the IV epi. I didn't push it in 5 seconds, more like 3 minutes. This was when I was still working EMS.