Completely innaccurate report!

  1. You're not going to believe what happened to me tonight! As soon as I walk in the door tonight I am told that I have to take report on a new admit from PACU. I take the report and am told that this is a gentleman who went for a hernia repair, and when they opened him up he was riddled with cancer and so they just did an open and close case. I write down all the info and accept the patient. I'm running around trying to care for 2 post op patients and the APRN and doc have the chart so I can't read a history or op notes. I photocopy the orders to work with them and eventually the surgeon comes up. I tentatively asked him what he told the family and he just said "oh patient is fine". I question him further about whether the family know about the terminal cancer and he looks at me as if I am crazy. He said "what are you talking about? The patient doesn't have cancer!". The PACU nurse had given me a completely untrue report!

    I was so embarrassed and horrified I called PACU straight away for an explanation. The PACU nurse was very defensive and angry and I explained that her report could have changed my care of the patient and she just didn't want to hear it. I couldn't believe I found myself justifying my phone call. I told her that it was unavoidable that I filled in a incident report and she just retorted that she was fed up with the unit and the hospital and I should do my worst. I'm not the kind of person to complain about someone, but what if I had said something to the family? I go cold when I think of what might have happened! Maybe if her reaction was different I would feel less inclined to fill out the form, but this is serious. She told me that she got that information from the anesthesiologist and was just passing it on, but I told her she should maybe have read the notes and history before calling a report. What do you guys think?
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    About Rocknurse, BSN, RN Pro

    Joined: May '03; Posts: 1,296; Likes: 4,566

    20 Comments

  3. by   Hellllllo Nurse
    I think you were right in what you did.
  4. by   CrunchRN
    Sounds like that nurse who gave report is suffering from care giver fatigue and feeling overwhelmed. Maybe the incident report will help her get some assistance if it is handled correctly by someone who is perceptive and has a heart. Horrible experience for you I can see and could really have turned into a huge mess. Hope it get's better for you.
  5. by   SmilingBluEyes
    Another reason to leave this position. I have to wonder what hellhole this is. I sure would not want me or mine hospitalized there. No personal offense to you....you are obviously very conscientious......

    but between this and the mandate of OT (did you DO IT?) you have all the clear signs pointing you to the DOOR.
  6. by   UM Review RN
    Quote from Rocknurse
    You're not going to believe what happened to me tonight! As soon as I walk in the door tonight I am told that I have to take report on a new admit from PACU. I take the report and am told that this is a gentleman who went for a hernia repair, and when they opened him up he was riddled with cancer and so they just did an open and close case. I write down all the info and accept the patient. I'm running around trying to care for 2 post op patients and the APRN and doc have the chart so I can't read a history or op notes. I photocopy the orders to work with them and eventually the surgeon comes up. I tentatively asked him what he told the family and he just said "oh patient is fine". I question him further about whether the family know about the terminal cancer and he looks at me as if I am crazy. He said "what are you talking about? The patient doesn't have cancer!". The PACU nurse had given me a completely untrue report!

    I was so embarrassed and horrified I called PACU straight away for an explanation. The PACU nurse was very defensive and angry and I explained that her report could have changed my care of the patient and she just didn't want to hear it. I couldn't believe I found myself justifying my phone call. I told her that it was unavoidable that I filled in a incident report and she just retorted that she was fed up with the unit and the hospital and I should do my worst. I'm not the kind of person to complain about someone, but what if I had said something to the family? I go cold when I think of what might have happened! Maybe if her reaction was different I would feel less inclined to fill out the form, but this is serious. She told me that she got that information from the anesthesiologist and was just passing it on, but I told her she should maybe have read the notes and history before calling a report. What do you guys think?
    Oh, I do hate those shifts when you have to hit the ground running!

    I've gotten Reports like that too, Rocknurse, so I completely sympathize. However, you handled it appropriately, no harm was done, and now you understand why some of us like to literally read the chart and the orders before we do or say anything to anyone.
  7. by   fergus51
    I wouldn't have filled an incident report over this because those seldom have the desired effect, but I would definitely have called the nurse to remind her things like this can happen.
  8. by   brigaily2000
    Quote from fergus51
    I wouldn't have filled an incident report over this because those seldom have the desired effect, but I would definitely have called the nurse to remind her things like this can happen.
    Yes, I would have filed an incident report. You did the right thing. I know it's prudent to read the chart, etc. etc., but when you are under seige with many sick patients and orders flying which way and that, you must reply on your report. The nurse should be kindly disiplined.
  9. by   sharann
    There is something wrong over there in that PACU because this is not normal or explainable. Now unless the surgeon is straight out lying(MY patient is fine)or the nurse is lying there has got to be an explanation. The only thing I can think of is that this PACU nurse got the patient secondhand, that is , she got report from another nurse who passed the patient on. Sometimes in PACU, one nurse will admit, another takes care of, and a third(believe it its true) transports/gives report. This is due to the constant flow of patients in from OR. This doesn't explain her nasty attitude. Sounds really burned out to me. I would also have written a repot up, just to cover the next time this happens.
  10. by   naggytabby
    one thing I noticed in your post is that both of you were basing your care on the verbal report from someone else, with the chart unavailable to both of you.
    please don't flame me, just an observation. perhaps what this points to is a systems problem.
  11. by   Rocknurse
    Quote from naggytabby
    one thing I noticed in your post is that both of you were basing your care on the verbal report from someone else, with the chart unavailable to both of you.
    please don't flame me, just an observation. perhaps what this points to is a systems problem.
    I see your point totally...but the difference is that I didn't give a report to another professional based on hearsay, and did not give any meds or treatment without looking at orders. It did change my perception of the patient and the psych/social/support issues surrounding them. There was nothing discernibly different in my approach but it threw me off. I was assuming that I was treating a dying patient with all the issues that go with that, and instead find that this is not the case. If I was going to call a report I would not do so without the chart in front of me. It's a little hard not to base your care on the report of the preceding nurse, as our job is often based on communication? However, the difference is in what you do after that. If I had given meds or treatment based on a verbal report that could spell trouble. Luckily I did not.

    According to the PACU nurse, she got that report from the anesthetist. Let's hope she learned a lesson from all this and in future makes sure she reads the chart before calling report on someone.
  12. by   Tweety
    You were right in trying to get to the bottom of the misinformation, and probably right in filling out an incident report, because something is gravely wrong if that kind of misinformation was passed on.

    Were you confrontational in your calll, did you perhaps cause her to get overly defensive and then the call deteriorated from there? I think when we find others in a mistake we can be a little gentler in our investigating. Just a thought.
  13. by   Rocknurse
    Quote from Tweety
    You were right in trying to get to the bottom of the misinformation, and probably right in filling out an incident report, because something is gravely wrong if that kind of misinformation was passed on.

    Were you confrontational in your calll, did you perhaps cause her to get overly defensive and then the call deteriorated from there? I think when we find others in a mistake we can be a little gentler in our investigating. Just a thought.
    Actually, you know I really wasn't. I was trying to be calm and professional and explain exactly why it was important that I received accurate information, but she seemed bent on arguing with me which I found odd. She really did sound burned out, and to honest I felt the same too. We have to deal with too much BS and in a way I sympathise with her, but at the end of the day, I need to cover my butt and that's what I did. Something like that must be documented because I do not want to be part of the fallout should it come back on me.
  14. by   Lawnurse
    Rocknurse, you did exactly the right thing by calling the PACU nurse (in case there was some reasonable explanation) and then writing up an incident report, esp. considering she did not take the blame for her mistake.

    Whether or not the incident report will truly solve the problem is not your primary concern- after all, NO good will come out of not writing one.

    Who knows why the PACU nurse gave such an inacuate report? There's a small chance its a sign of something really going on with the reporting nurse (cognitive deficit, "impaired nurse" syndrome, actual incompetence) which you may have shed light on.

    Good for you for standing up for yourself! IMHO, nurses standing up for themselves more frequently is one of the things the profession needs the MOST. :1luvu:

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