First Incident Report

[gemmi999]

I made my first incident report today and I feel conflicted. Here's the situation:

I'm an ER nurse. I got report from RN about four pts. Of those four pts:

1) one had a potassium level of 2.4 and was not on a heart monitor. Instead, laying in bed with no monitor; when I asked if potassium had been given RN stated oral potassium. I asked why pt. wasn't in room with monitor because he had one open and RN stated that was not the room that had been assigned when pt. first came in.

2) one had new onset facial drooping, expressive aphasia; I asked day shift RN if pt. had had stroke--was told no, had had one four days previously. I asked about new symptoms, RN again stated no CVA. I checked admission orders, admitted for CVA. I again asked RN and RN said no CVA. Had to call MD to get clear pt. history and diagnosis.

That part I was glad to report because I felt the RN had been unsafe with pt. care. However, the evening this happened I asked the Charge RN if I should do an incident report and Charge stated I should verbally talk with RN or Charge RN and not do an incident report.

This is a charge RN I work with a lot and I tend to respect his opinion, but this felt wrong to me so I double checked with ER manager. ER manager stated to write it up. I also documented what Charge RN stated and I feel conflicted about this.

Does this mean I'm a "tattle tale?" and carrying things to management? I don't want to do that but I want to make sure this situation doesn't happen again...So now I feel conflicted.

[AnnieOaklyRN, BSN, RN, EMT-P]

I am going to guess at this, and you can tell me if you are wrong. Are you a new ER nurse?

There are times in the ER when things, like previous CVA, or history of CVA are not communicated with the primary RN, and when the ER is so short staffed you don't have time to look, as long as the patient is stable. I understand your frustration, but this may have been lack of physician to nurse communication more than anything.

If you told me the patient was hypERkalemic I would be more concerned that he or she was not on a monitor. Yes, 2.4 is low for a K, but chances are high that nothing is going to happen cardiac wise, especially since some was given PO. A person with normal kidney function is less of a worry than someone with renal disease. Did this patient have any renal issues (I would assume not since they were low). Patients with hyperkalemia are much more worrisome!

My advise is to talk to the nurse in person if you feel that strongly about it. I would not write an incident report, that will only make waves, and will make you look bad. Always work your way up, don't start from the top when dealing with issues with co-workers!

Annie

[AmeliasAunt]

Are you talking about incident reports or write-ups? An incident report (in my world) is an anonymous reporting system for various issues or events that do not follow policy or present harm to the patient. These do not require names of the nurses involved and are used as a tool to improve processes. A write-up is (again, in my world) is documenting certain actions by certain individuals and reporting that to management. If you completed an incident report I would not consider that tattling or even give it a second thought. A write-up might stick around for awhile. Also, I know nothing about working in the ED so I can't comment on the particulars. :)

[ED Nurse, RN]

I'm going to have to agree with Annie- you sound like a new RN. I don't see anything you can write a true incident report for. If you are speaking of a write up then I wouldn't do that either. If you have an issue you need to settle it at the lowest level first, which would be speaking with the nurse you had the issue with. You will not get far in nursing if you can't have conversations with co-workers about disagreements and run to management every time you have a problem. If you are a true ED RN then you should know these are pretty petty issues- new CVA vs old CVA are totally different- if the pt had gotten tpa then yes that would be a big deal not to know, but that's not the case here. A potassium of 2.4- again not a huge deal, easily corrected and not life threatening. Nothin bothers me more than people who can't communicate with their co-workers and would rather throw them under the bus instead of trying to get to the bottom of the issue at hand.

[Been there,done that, ASN, RN]

Any time you feel unsafe care was given.. feel free to document. You are not "tattle tailing". You are recording YOUR observation.

I am surprised other posters feel a K+ level of 2.4 is not an emergent event, requiring a cardiac monitor and IV supplementation. I would anticipate any arrhythmia to occur at that level.

[Been there,done that, ASN, RN]

I'm going to have to agree with Annie- you sound like a new RN. I don't see anything you can write a true incident report for. If you are speaking of a write up then I wouldn't do that either. If you have an issue you need to settle it at the lowest level first, which would be speaking with the nurse you had the issue with. You will not get far in nursing if you can't have conversations with co-workers about disagreements and run to management every time you have a problem. If you are a true ED RN then you should know these are pretty petty issues- new CVA vs old CVA are totally different- if the pt had gotten tpa then yes that would be a big deal not to know, but that's not the case here. A potassium of 2.4- again not a huge deal, easily corrected and not life threatening. Nothin bothers me more than people who can't communicate with their co-workers and would rather throw them under the bus instead of trying to get to the bottom of the issue at hand.

2.4 potassium is a very huge deal. A severe deficiency that can cause any ventricular or atrial arrhythmia. Is it easily correctable? Not if the patient is having significant GI loss.

I would write up any nurse in a heart beat (haha) if the patient was not placed on a cardiac monitor.

Review your facility's protocol, please. You are way too cavalier regarding a life threatening electrolyte imbalance.

[ED Nurse, RN]

Are you a critical care nurse? A potassium of 2.4 is something I see in the ER on a daily basis- depending upon the cause, most are sent home after PO potassium has been given. In 8 years of nursing I have never seen a cardiac dysrthymia from a potassium like that. I have seen dysrthymia from hyper K numerous times. I am well aware of my hospitals policy and pts with a potassium of 2.4 that are admitted don't usually even get admitted on telemetry unless they are having an infusion of potassium. ED providers have bigger issues than a potassium of 2.4 and an old CVA. If you can't know the difference between what is critical vs what is not then the ED is not a place for you- I'm sure floor nurses however feel as though those details are important bc those are the things they treat and have time to address. In the ED we "pick our battles." Again, if you have never worked in an ED or are a new nurse these are not things you will understand. It's not bad practice by any means. We do things differently depending on the department you work in.

[ED Nurse, RN]

And btw, I am FAR from cavalier. I just know how to prioritize and get things done and have never once received a write up for ANYTHING. I provide excellent, expert, and precise care for everyone of my patients. Please refrain from making a generalization about me when you don't know my personal practice. To me, you just sound like someone who has never worked in an ED and you should not make judgements about a practice you don't know.

[kaylee.]

Medscape: Medscape Access

I dont work in the ED so I dont know how things are dealt with but according to this medscape page, the patient is in the category of "severe hypokalemia". This makes sense to me and up on tele, they would be on a monitor, have gotten an ekg, and iv k would be going. If the k is 2.4 it could be dropping more. And the op had justified reason for concern.

[ED Nurse, RN]

I never said the value to not need to be treated, however a K of 2.4 in the ER is not emergent. My point to all of this is that the OP needs to speak to her fellow nurse about the issues- you are putting yourself in a bad position if you run to management before trying to solve the issue at hand. We are adults and professionals, lets act like it. It's a TEAM.

[Been there,done that, ASN, RN]

Are you a critical care nurse? A potassium of 2.4 is something I see in the ER on a daily basis- depending upon the cause, most are sent home after PO potassium has been given. In 8 years of nursing I have never seen a cardiac dysrthymia from a potassium like that. I have seen dysrthymia from hyper K numerous times. I am well aware of my hospitals policy and pts with a potassium of 2.4 that are admitted don't usually even get admitted on telemetry unless they are having an infusion of potassium. ED providers have bigger issues than a potassium of 2.4 and an old CVA. If you can't know the difference between what is critical vs what is not then the ED is not a place for you- I'm sure floor nurses however feel as though those details are important bc those are the things they treat and have time to address. In the ED we "pick our battles." Again, if you have never worked in an ED or are a new nurse these are not things you will understand. It's not bad practice by any means. We do things differently depending on the department you work in.

34 years experience , worked ICU and ER. I am getting a whiff of treat 'em and street 'em. How much oral supplementation would it take to correct 2.4? That much Kdur would give anybody GI distress. Do you draw another level before you discharge? That would entail at least 6 hours in your ER. Your facility would get PAYMENT for at least an observation.

I personally experienced an atrial dysrhythmia at 3.2. Witnessed many as the nurse. For what it's worth, my position now is to authorize or deny hospital admissions. A K+ level of 2.4 is a slam dunk full admission. The screening tool I use, does not give up admissions easily. It applies evidence based criteria, researched by many disciplines.

[gemmi999]

I'm a new ED nurse, but in the six months I've worked I have already seen a pt. crash with a potassium of 2.5. That pt. didn't survive. So when I saw this pt. with a potassium of even less then that in the ED, not on a heart monitor, in a room that is infrequently monitored (because a lot of nurses think '2.4 isn't a big deal'") then yes, I did an incident report. I spoke with the RN twice about it prior and the RN didn't particularly care about the risk the pt. was at. Once this pt. was moved to a monitor I saw her throw continuous PVCs, as well as couplets. Nothing fatal but given the pt's other health history and concerns, I feel like I made the right decision. Additionally--this pt. had an PT of 93.5 and an INR > 10. Neither of which was disclosed during report.

The other pt? It wasn't a past CVA, which is what the report RN told me. They had had the CVA that day. To not know past history of stroke, fine, not a big deal. I get reports like that all the time. To not know that your pt. was in the ER that day due to new onset CVA and was having right sided deficits. To give your pt. full glasses of water when asked even if they can't move tongue/entire side of face and not think about aspiration precautions. Especially when pt. is NPO per both ERMD and admitting doctor. Ugh.

Again, I'm new but maybe that's a good thing. I'm less cynical about what I've already seen and more cautious with pt. safety. I'd rather do one incident report now versus have an investigation into causes for a pt. death later.