Need advice on a sentinel event please!

  1. deleted
    Last edit by mst31 on Apr 25, '07 : Reason: deleted
  2. Visit mst31 profile page

    About mst31

    Joined: Jan '06; Posts: 20
    Critical care RN
    Specialty: 1 year(s) of experience


  3. by   TiffyRN
    For you own protection I would seriously erase everything you've written up to this point and read other posts. Than we can advise how to handle yourself if facing a meeting with the board. This board is not always as anonymous as you might like to think.
  4. by   TazziRN
    No way to know. BONs take each complaint individually and investigate each. They investigate the occurence, the result, and any action taken by the hospital.

    I would suggest an attorney with experience dealing with BONs.
  5. by   TazziRN
    And what Tiffy said......very good point.
  6. by   neneRN
    ...and no one asked if she was a diabetic...The charge nurse, house supervisor, and doctor were all involved and no one gave me a clue to check BG. Well, pt went to ICU after becoming nonresponsive and it was determined that BG was 9. I repeatedly asked if she should be arouseable post ictal and was informed by 2 critical care nurses with many years of experience to just let her rest.

    This is the only part of your post that disturbs me...this was your patient, and it wasn't the responsibility of anyone else to "give you a clue" about checking a glucose. You knew that the patient was diabetic and you knew that you had given insulin. Checking glucose is a very basic intervention in any patient with ALOC or new seizures with a Hx of DM and it should have been done.

    That said, I do empathise with your situation and I'm sorry you're going through this. I don't know that this is retaliation for you leaving... Risk management is always involved in cases like these and although your hospital deemed your immediate recourse would be further education, it was most likely reported sometime during the investigation and you're just now hearing about it. If the hospital truly felt you were dangerous, you would not have been allowed to continue to work as that would be a liability issue if any further incidents occurred after thay had deemed you unsafe- doesn't sound like the case here. When peer reviews are done, there are policies that have to be followed in reporting some incidents to certain agencies regardless of how the hospital sees it and your case may have fallen into this category.

    I would talk to an attorney...this may be something where you end up with a slap on the wrist, but don't chance it.
  7. by   Medic/Nurse
    I can understand your confusion - and the timing may be suspect, but a report has been made to the BNE and now it must be addressed.

    The "motivation" behind it WILL NOT change the issue.

    First, you noted a "sentinel event". You describe a medication error - then you note peer review and no discipline toward you except diabetes education. What was the end outcome for the patient? I hate to assume - but I suspect the patient either died or was left with serious disability.

    FYI- there are certain meds that I always verify with another RN - INSULIN is one of them. Did your facility have a high alert/double verification for insulin? Did you follow their policy for this medication?

    You admit an error where FIVE (5) ADDITIONAL units of insulin were administered - and this patient seized, became obtunded and _____ (outcome). You note that many others responded/cared for this patient and NO ONE picked up on the blood sugar. Wow!

    I have no experience that supports that only 5 units of insulin could produce the clinical consequences that you describe. You noted that 10 units were indicated by sliding scale - at what point was the blood glucose checked after the "incident". Did someone do another finger stick or POC test, or did the routine labs show the glucose of 9? Was this patient a diabetic? You noted "high dose not unusual" and "resistance". You also note that this event took place 6 hours following med administration. What kind of insulin?

    In any event - mistakes were made. But, EVERYONE will make mistakes. It just appears that this one had some serious consequences.

    Just because "they" let you work without discipline and "allowed" you plenty of OT does not keep them from reporting an issue to the BNE. The patient had a bad outcome. I'm not trying to judge, but it does appear that a standard of care may have been deviated from - so...

    You are a new nurse with less than a year at your first job. You admit a sentinel event. Your facility has reported the situation to the board for review. You will need to respond. I hope that you have copies of any correspondence that the facility had with you (write up) or that you had with the facility. Hopefully, you wrote (for your benefit) the entire event out with timeline - including the others involved in care of the patient. Memory is a strange thing.

    YOU NEED TO TAKE THIS SERIOUSLY. Don't get stuck on the issue of WHY this was reported. Even if they reported you to "get even" for you quitting - the BNE will handle the "complaint" just like any other! I think you may have some problems. Heck, don't even answer the questions I have posted. I think I'd get qualified counsel right away. I'd look for a nurse lawyer. There is no way that I would go to the BNE alone. I am concerned for you.
  8. by   Susan9608
    Sometimes, as one of their benefits, hospitals offer legal assistance; you should contact your HR department and ask them if your hospital provides that benefit.

    If not, there is a free legal forum on the internet, where you can post your case to an attorney to get legal questions answered. The site is Perhaps they can point you in the right direction for how to obtain a medical malpractice attorney.

    Good luck to you.
  9. by   MrChicagoRN
    Quote from TiffyRN
    For you own protection I would seriously erase everything you've written up to this point and read other posts. Than we can advise how to handle yourself if facing a meeting with the board. This board is not always as anonymous as you might like to think.

    Excellent point.

    Then you call up your local bar association & get the name of a lawyer who specializes in this.

    It may have truly taken time for the case to work it's way throught the system. Sentinal events must be reported. Peer review isn't the end of it. You made an error, but safeguards weren't in place to reverse what happened in a timely manner.

    The state is probably going to investigate the hospital. Perhaps the patient or family plan to sue.

    You are inexperienced.
    Mistakes happen, unfortunately, but you need to protect your interests.

    This is all very scary, but you need to protect yourself. Your share of this is your share of this. Don't take anyone else's share.

    Delete your post (edit out all the text) & talk to a lawyer.