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.
I'm not an ER nurse, but I can identify with your feeling conflicted and your frustration as to patient's not receiving the care that you thought they should.
A couple of things that come to mind:
Sometimes I've found there are extenuating circumstances that I wasn't initially aware of - not that it excuses lower quality care, but it may have impacted the quality of care provided. Sometimes it works to ask the person questions in a way that opens up a dialogue and not just the obvious/ simple questions or triggers a defensive reaction.
All of these are considerations in doing "the right thing" - both in ensuring quality care for your patients as well as appropriately addressing concerns. It's an ongoing learning process unfortunately.
Welcome to ER nursing. The average ER is understaffed and over populated with patients, so you will be writing a lot of incident reports during your time there, at least until you become crisp in a couple years!
This is reality and happens everyday in ERs across the country, not just in yours. As long as ERs are continued to be understaffed and patents continue to abuse the system it will remain that way, you have to learn to cope with the fact that in a busy ER you just can't give "perfect" care to your patients. It isn't an ICU where you have 2 patients!!
Annie
I'm gonna disagree on the potassium part. I've seen a patient go into torsades with a potassium of 3.2. Unresponsive and shocked them and got them back. But the point is that it can happen. If it can happen then you better be doing everything you can. Due diligence, telemetry. Hooking someone up on telemetry is easy and simple, and it can identify early if things start going bad so why not do it?
As a critical care nurse K+ of 2.4 is something to worry about but the way you handled it was wrong. The patient had no adverse effect of not being on the monitor (i.e. No lethal arrhythmias) according to you, so you should have put the monitor on and did what you needed to do and had a right then and there convo with primary RN. That should have been the end of the story. You are going to make enemies and in ER you need to rely on each other, you are going to make your life harder. What happens when a patient comes in with a problem you have never dealt with before and don't implement a timely intervention bc you didn't know? Now you have opened Pandora's box for the other nurses to write you up.
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.
You don't think it's necessary to monitor patients with a K of 2.4 because you've never seen then have arrhythmias before? That's an "if a tree falls in the woods and there's nobody there to here it" kind of argument. It's like saying "I've never seen a patient with sepsis become hypotensive because I never check their blood pressure, and because I've never seen a sepsis patient with a low blood pressure, I don't see why I should check their blood pressure". The vast majority of people being treated for a critically low potassium will do just fine while being treated, some won't, cardiac monitoring is how we can the difference between the two.
I think something you'll learn as you go forward is that your attempts will be far more successful when you discuss disagreements about proper care directly with other nurses. I work with some of the best nurses I've ever met in the ED, and I also work with some of the worst. That's the interesting thing about EDs, they're conducive to such widely varying practice standards. So for some nurses you can appeal to their desire to give better care, for others you can appeal to their desire to make their jobs easier. An easy, low time demand way to evaluate potassium replacement is to have them on a monitor. Some patients' rhythm and ectopy doesn't give away anything about their k/mag levels, for others the monitors can be very indicitive if whether or not you're heading in the right direction.
I agree, where in my pp i said i personally would have been concerned with a k of 2.4. I would definitely be frustrated with recieving a patient like this not on monitor etc. but my personality is one where i would have dealt with securing the patient, and maybe brought it up to the charge nurse, the situation i received the pt in, but would not have gone to management or written an incident report.
thats just me.
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.
.
Don't ever ask someone for guidance (which their advise was solid) and then use their name in a write up. Just to be totally honest...... that was a mean thing to do. A manager will ALWAYS tell you to write up an incident regardless if it's little or big.... But if you want to not be talked about and disliked you should follow your charge nurses advice . Talking to your colleagues and giving peer feedback is the better route .
BTW, oral potassium is the better choice if it can be tolerated and will change their numbers faster..... No need for a cardiac monitor if they are asymptomatic.
My only advice to you is that you can see (clearly) from the responses that the potassium issue is one that some nurses and some facilities deal with differently.
I always like to go with talking to my team members first and trying to keep that communication open unless REAL patient harm HAPPENED or was IMMINENT. Then I would do some sort of write up. Otherwise, I have found that (like another person said), management will always tell you to do one, but that usually doesn't help your work environment.
In my 5.5 years as a nurse, I have made my mistakes, felt like people were overreacting about some things I thought weren't that serious, and also been the person overreacting (but I got a little more experience regarding whatever it was and realized the "big picture"). There have also been times I have *legitimate* concerns for patient well being. It just takes a little time to figure out whats what. Now, I can't tell you which this falls in because I don't know the whole picture, but I hope everything works out for you.
DNo need for a cardiac monitor if they are asymptomatic.
I suggest reviewing hypokalemia and the treatment of at a site such as Medscape, as you appear to lack fundamental knowledge of how serious this condition can be, and appear not to understand why cardiac monitoring is important for hypokalemia. Please remember that the elderly, the very young, and patients with serious co-morbidities, have far less ability to tolerate arrhythmias and other complications of hypokalemia.
Been there,done that, ASN, RN
7,241 Posts
Exactly! Better to be safe than sorry. Anyone coming through the ED door deserves a cardiac monitor. It is readily available and will give volumes of info on the patient's condition. Keep up the good work.