First patient fall...

Published

So I had my first patient fall, not sure if ill get criticism or consoling, but I'm doing this to vent a little... So I have almost hit my first year of being an RN never had a fall until now. I work on a dumping ground type of unit with tons of different sick patients, so basically a med/surg/pulmonary/telemetry. I got a transfer from a higher level of care on my first day of work in a semi private room, the patient was a wreck, RR in high 20's, constant pain medications, O2, ETOH intake, etc. etc. and a normal patient about to be discharged the next day in the next bed.

Well all my focus was on the transfer patient the next day, bed 1 crazy sick, I had to fight with the providers to get to look at them and eventually get antibiotics and specialty providers involved, in my professional opinion, I wanted them transferred back to the higher level of care unit, the floor Doctor ultimately refused. Bed two started to over hear what was going on with bed 1 with the doctors talking to the patient and family and how her prognosis was and what not. Well all day the patient had to get up and use the bathroom due to diuretics and called all day for help to use the bedside commode; from me, the tech and whoever got to the call bell. Well throughout the day the bed alarm somehow didn't get turned on, I remember pushing the buttons, but didn't pay attention if they actually activated because bed 1 was so anxious and sick I kept coming over to them. On top of these 2 patients I have 4 other patients to keep up with as well.

A few more hours later, I took my bed 1 somewhere for a test, ultimately bed 2 decided she wanted to get up to use the bathroom and didn't use the call bell. We heard them fall saying help, we all ran in; the patient was hurt and hit their head, I asked them why they decided not to call vs all the other times they called and they said "I overheard that my neighbor was sicker than me, so I didn't want to bother you". We did everything from CT and X-rays to look for fractures and other injuries. No fractures but they ended up having an injury to their head. I contacted neuro surgery and did neuro checks every 30mins to 1 hour until my shift was over, plus more, I stayed an extra 2 hours to make sure the patient was okay and the orders were put in correctly.

I got an confirmation from my director that the patient was OK and pending discharge. But from what my coworkers said recently, administration is angry about the fall and is threatening a lot of repercussions for the next fall for anyone.

I understand the Bed alarm was not on and I'm not sure why it wasn't on, We help each other on our unit with bathroom and what not, so it could have been me, a tech or even another nurse, but ultimately It was failed to put it on, we do not know who, but I still accept responsibility because I'm the RN, I was in an out of the same room all day I should have been more diligent on looking at the bed alarms. I have always impressed administration and my patients, my name is constantly mentioned by patient on HCAHPS and even providers mention how attentive I am and how I "think above my level" I'm so disappointed in my self for letting something like this happen, I'm hopefully transferring to ICU soon and I feel like I don't deserve it now, my coworkers keep telling me to "stop beating yourself up" but I can't seem to help it. I made work harder for anyone else with the looming "next fall you will be fired" type of deal and I feel like I caused it.

*I tried to keep the patient information private by not using Genders and using Vague descriptions, if it is too confusing, I just put "bed 1" and "bed 2"*

Up Vote Up Vote ×

I understand how you feel. I just got out of a horrible shift myself that made me feel like I'm the worst nurse ever. We all have those days where we feel out of our game or where something would just go wrong no matter how careful we try to be. It happens to the best of us and you did well to rectify the situation. I agree with those who tell you to not beat yourself up over this. Whatever compliment you have received before, I'm sure you earned it. Don't let this incident break your confidence and use it as a learning experience instead. Best of luck!

Up Vote Up Vote ×
Specializes in Med/Surge, Psych, LTC, Home Health.

Unfortunately, falls are just going to happen. Admin hates it, hates it, double

hates it when they happen... but they do happen. You did everything you could

to prevent this one, and it still happened. Document everything. Then once

you document everything that you did to prevent a fall... might as well

stop worrying.

One question... does your floor have techs, aides, CNA's.. ???

Up Vote Up Vote ×

Falls are gonna happen. Bed alarms are for confused patients... just another beep, by the time they are out of bed.. they can fall before any body can respond. Do not let administration run over you... it was an accident.

Up Vote Up Vote ×
Specializes in Med/Surge, Psych, LTC, Home Health.

Plus, I've had patients figure out how the bed alarms work and they

just disable them.

Up Vote Up Vote ×
Specializes in Critical care.

Another nurse I worked with stated that falls happen as a result of poor staffing and I absolutely believe that. I used to work on a unit similar to yours and it's impossible to prevent all falls. We went months with no falls at one point then started having a couple falls a month- administration was mad, but we nothing in our habits had changed to cause all the falls suddenly. We busted our butts, but it didn't seem to make a difference. Bed and chair alarms are just reactionary- as BTDT has said by the time they go off the patient can be on the floor. I responded within 10 seconds one time and the patient was already on the floor and we had done everything right to prevent the fall. Stop beating yourself up about it- if it wasn't you, it would have been somebody else.

Up Vote Up Vote ×
So I had my first patient fall, not sure if ill get criticism or consoling, but I'm doing this to vent a little... So I have almost hit my first year of being an RN never had a fall until now. I work on a dumping ground type of unit with tons of different sick patients, so basically a med/surg/pulmonary/telemetry. I got a transfer from a higher level of care on my first day of work in a semi private room, the patient was a wreck, RR in high 20's, constant pain medications, O2, ETOH intake, etc. etc. and a normal patient about to be discharged the next day in the next bed.

Well all my focus was on the transfer patient the next day, bed 1 crazy sick, I had to fight with the providers to get to look at them and eventually get antibiotics and specialty providers involved, in my professional opinion, I wanted them transferred back to the higher level of care unit, the floor Doctor ultimately refused. Bed two started to over hear what was going on with bed 1 with the doctors talking to the patient and family and how her prognosis was and what not. Well all day the patient had to get up and use the bathroom due to diuretics and called all day for help to use the bedside commode; from me, the tech and whoever got to the call bell. Well throughout the day the bed alarm somehow didn't get turned on, I remember pushing the buttons, but didn't pay attention if they actually activated because bed 1 was so anxious and sick I kept coming over to them. On top of these 2 patients I have 4 other patients to keep up with as well.

A few more hours later, I took my bed 1 somewhere for a test, ultimately bed 2 decided she wanted to get up to use the bathroom and didn't use the call bell. We heard them fall saying help, we all ran in; the patient was hurt and hit their head, I asked them why they decided not to call vs all the other times they called and they said "I overheard that my neighbor was sicker than me, so I didn't want to bother you". We did everything from CT and X-rays to look for fractures and other injuries. No fractures but they ended up having an injury to their head. I contacted neuro surgery and did neuro checks every 30mins to 1 hour until my shift was over, plus more, I stayed an extra 2 hours to make sure the patient was okay and the orders were put in correctly.

I got an confirmation from my director that the patient was OK and pending discharge. But from what my coworkers said recently, administration is angry about the fall and is threatening a lot of repercussions for the next fall for anyone.

I understand the Bed alarm was not on and I'm not sure why it wasn't on, We help each other on our unit with bathroom and what not, so it could have been me, a tech or even another nurse, but ultimately It was failed to put it on, we do not know who, but I still accept responsibility because I'm the RN, I was in an out of the same room all day I should have been more diligent on looking at the bed alarms. I have always impressed administration and my patients, my name is constantly mentioned by patient on HCAHPS and even providers mention how attentive I am and how I "think above my level" I'm so disappointed in my self for letting something like this happen, I'm hopefully transferring to ICU soon and I feel like I don't deserve it now, my coworkers keep telling me to "stop beating yourself up" but I can't seem to help it. I made work harder for anyone else with the looming "next fall you will be fired" type of deal and I feel like I caused it.

*I tried to keep the patient information private by not using Genders and using Vague descriptions, if it is too confusing, I just put "bed 1" and "bed 2"*

"I got an confirmation from my director that the patient was OK and pending discharge. But from what my coworkers said recently, administration is angry about the fall and is threatening a lot of repercussions for the next fall for anyone."

Stop getting your information from the rumor mill.

When I know I will be having a discussion with a boss, I go find them, rather than the other way around. Right now, you are just waiting to be called into an office, and expecting to be berated. That is not a productive way to view the situation. You are a professional- take control of the situation. You and your boss actually have a lot in common in dealing with this situation. You both are concerned about the fact that a PT fell, and would like to minimize future falls.

Think about how different it would feel if you proactively went to your boss- "Hi Wendy. We had a patient fall on Tuesday, and I wanted to talk with you about it. When would be a good time to meet?" You and Wendy are going to have this conversation anyway- have it on your terms.

If having that bed alarm on is a policy, and it is your job to ensure that it is on, then you made an error. It was a human error. Being human, a certain amount of these are going to happen. They will happen more frequently in the chaotic situation you described. Own the error. Discussing the environment that contributed to it, and possible ideas for process improvement, are completely appropriate. And completely separate from your ownership of the error.

Also- I recommend you read your OP, and look at the language you use, and how that reflects your feelings about your workplace. From what I read, you work in a dumping ground, and are supervised by angry, vindictive, irrational bosses intent on maintaining control through fear and group punishment. "I made work harder for anyone else with the looming "next fall you will be fired" type of deal and I feel like I caused it."

If that is accurate, give some serious thought to looking for another job.

Up Vote Up Vote ×
Specializes in Emergency, Telemetry, Transplant.

As others have said falls happen. Learn from it, try to prevent them in the future....but realize that they will still occur even with almost every possible intervention. Also, I want to second the thought of not to listen to the rumor mill. Perhaps the nurse that told you about the crackdown on falls is on administrations radar because he/she has had an exceptionally large number of falls--or they heard it from someone who is on administration radar for the same. If every administration crackdown I heard about were true, most people would not have a job.

As an aside, I worked in a hospital where one of the med-surg units was trialing a "fall contract" with each patient. Every new admit to the unit who was a fall risk would have to sign a paper that basically says that they know they are a fall risk, they will never get up unassisted, and they promise to ring every time they want to get up. If this contract was not posted on the door, the nurse would get a nasty gram email. Not sure if this would ever turn into real disciplinary action, but it was yet another pointless thing that did nothing to work toward solving the problem...other than make staff bitter for getting yet another nasty gram.

Up Vote Up Vote ×

Yeah my floor has Techs, depending on the staffing 2-3 for 35 patients max.

Up Vote Up Vote ×
Unfortunately, falls are just going to happen. Admin hates it, hates it, double

hates it when they happen... but they do happen. You did everything you could

to prevent this one, and it still happened. Document everything. Then once

you document everything that you did to prevent a fall... might as well

stop worrying.

One question... does your floor have techs, aides, CNA's.. ???

Yeah my floor has Techs, depending on the staffing 2-3 for 35 patients max.

Up Vote Up Vote ×
"I got an confirmation from my director that the patient was OK and pending discharge. But from what my coworkers said recently, administration is angry about the fall and is threatening a lot of repercussions for the next fall for anyone."

Stop getting your information from the rumor mill.

When I know I will be having a discussion with a boss, I go find them, rather than the other way around. Right now, you are just waiting to be called into an office, and expecting to be berated. That is not a productive way to view the situation. You are a professional- take control of the situation. You and your boss actually have a lot in common in dealing with this situation. You both are concerned about the fact that a PT fell, and would like to minimize future falls.

Think about how different it would feel if you proactively went to your boss- "Hi Wendy. We had a patient fall on Tuesday, and I wanted to talk with you about it. When would be a good time to meet?" You and Wendy are going to have this conversation anyway- have it on your terms.

If having that bed alarm on is a policy, and it is your job to ensure that it is on, then you made an error. It was a human error. Being human, a certain amount of these are going to happen. They will happen more frequently in the chaotic situation you described. Own the error. Discussing the environment that contributed to it, and possible ideas for process improvement, are completely appropriate. And completely separate from your ownership of the error.

Also- I recommend you read your OP, and look at the language you use, and how that reflects your feelings about your workplace. From what I read, you work in a dumping ground, and are supervised by angry, vindictive, irrational bosses intent on maintaining control through fear and group punishment. "I made work harder for anyone else with the looming "next fall you will be fired" type of deal and I feel like I caused it."

If that is accurate, give some serious thought to looking for another job.

Thank you for your post, opens a lot for me, I have talked to my director over the phone, but not in person about it yet, I will soon. And yes my floor or...hospital is pretty toxic with administration, its rough, more seasoned nurses (sorry to go back to the rumor mill) Have experienced this before and they always say "its nothing new, its always been like this"

Either way, thank you. I did own up to the error, I wasn't about to start pointing fingers or making excuses, what done is done.

Up Vote Up Vote ×
Specializes in Case manager, float pool, and more.

It happens, even with every precaution in place. It sounds like you were doing the best you could with what was going on.

Up Vote Up Vote ×
+ Join the Discussion