Have any of you ever lost a patient?

Nurses General Nursing

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Specializes in Med-Surg.

As in lost, not expired... Well, this just happened to me a few days ago, and I'm still shaken up about it. I had just started my shift and the craziness they call bedside report (which was just implemented in the med-surg units). His room was my first stop, and he was sitting on his bed wearing street clothes instead of the hospital gown. Odd? Maybe, but he has an extensive Hx of CVAs and dementia, so some things he does are not considered "normal" anyway. So, the outgoing nurse doesn't like bedside reporting and stood at the doorway while giving report. We moved on to the next rooms and all is well. A few mins. later (still doing report), I see my PCA and another nurse escort him back into the room, as he was wondering the hall. When the PCA went back to do VS, he was gone, and she immediately came to tell me. To say I panicked is an understatement! I searched the entire unit (pretty big) and couldn't find him... Stairwells, elevators, even outside, and nothing! I informed the charge nurse who, in turn, called security and the nursing supervisor. Everyone was mobilized, but he was still nowhere to be found!

I was so mad because it seemed that security and the police weren't doing enough! The investigator looked like he was on his first day at the job! I spent most of my shift shuffling back and forth between my other patients and the security office looking at the tapes trying to figure out if he had, in fact, left the hospital. The family was informed, but they didn't seem concerned as "he does this all the time." All I could think of was that if this was my parent, I'd be hightailing it to the hospital trying to find him! All the big wigs were telling me everything would be all right, that I didn't need to worry, that my bases were covered, and that there was nothing I could've done differently. After all, it's not like we can physically prevent anyone from leaving if they so desire! Rationally, I understood what they were saying, but that didn't keep me from worrying that this confused, elderly man may have been wandering outside and possibly gotten hurt, or worse.

It seemed no one understood that I wasn't worrying about my behind, but about him! Screw the job, this is a person we're talking about! By the time I left after my shift, he was still missing, even though they had "searched everywhere" in the hospital. My coworkers and managers were very supportive, which made me feel very grateful and made me remember that I'm lucky to work with such wonderful staff, even though this job is less than ideal. Thankfully, they found him unharmed, 24 hours later, hiding in plain sight. They took him to ER to get him checked out, and I haven't heard anything else from this ordeal. I'm just extremely thankful that they found him and that he never left the grounds. I can only imagine what could've happened. So my question is, has anything like this happened to you, or on your unit?

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MIA for 24 hours, and nobody cares? If this was LTC, the state would have shut the facility down. Immediate jeopardy would have been an improvement.... The family knew he did this, and didn't provide either enough info proactively (and stay with the guy) or give a rat's tail after the fact. Great. :uhoh3:

Yes- I'd be upset. I'd probably be more angry that I didn't have the actual risk factor of the patient....the hospital can either get the family in to sit, or get a sitter- even if it's someone outside the door. A bed alarm is nice- but would likely need staffing adjustments for someone that "busy".....

Not gonna be long before there are locked dementia units in acute care- hard to believe they aren't already out there. ????

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Well I was on the other end of it. I was coming on and the off going nurse was giving bedside report as well and the patient was GONE. He was in his 60's and had come in for foot pain I believe, he had an IV as well (not good) so we overhead paged him and 20 mintues later turns out he was in the waiting room because he didn't want to sit in the stretcher in the ER. I mean the biggest issue with this situation was him having an IV, but it would've been hell if he was an elderly dementia patient. Scary.

I used to work in a nursing home and had the occasional wanderer so I know the panic.

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Specializes in CMSRN.

Yes, this has happened to me. I had an elderly dementia pt who had the agility of a 30 year old. I was in front of her room too. I turned to get a chart and did not notice she walked out the room. She was FAST. But she was sweet too.

A coworker called me from the other nurses station on the same floor but other side of hospital. (I did not even know she was gone)The pt remembered she was in room 40 but that she was looking for her friend on the floor above (there is no floor above us).

I met them half way and the pt was just talking up a storm to my co-worker.

Luckily the trip made her tired and she slept the rest of the night in bed.

Scared the bejeezus of of me.

She got a bed alarm after that. But only helped partially. If you were not there to see her then she could be gone before you got to the room. A sitter was not available.

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Yeah reminds me of how we'd beg management (nursing home) for an extra cna for a one to one, but they wouldn't budge, so we were left with having to do our work, plus chase the little lady in bed 10 around the floor.

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Many, many years ago, while I was working at a nursing home in downtown Philly, we had an outside BBQ for the patients, and a Parkinson's pt wandered off. This little old man shuffled about 10 blocks away!!! Up and down curbs, crossing big, busy streets!! Luckily, he was wearing an ID band, and the cops found him and brought him back.

Scary!

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Specializes in Professional Development Specialist.

It wasn't my patient, but I was on that night. We searched the entire facility and the patient was no where to be found. Thankfully the patient was found before any harm occurred, but had it been 20 minutes later, who knows. Every time I can't find a patient, I flash back to that scary moment when he was found.

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Specializes in family practice.

This happened to my co-worker last month. We had just started on the unit and he was assigned a pt with TB who had been in isolation for 2weeks. he went on break and the other nurse at that station was in a room with another pt. Alas when he got to her room she was no where to be found and she left a note saying that she had left the hospital. She was found hours later at the laundromat with family. She was brought back where she spent an extra week i believe. Thank God we live in a really small town.

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Specializes in Med/Surg, Academics.
Yes, this has happened to me. I had an elderly dementia pt who had the agility of a 30 year old. I was in front of her room too. I turned to get a chart and did not notice she walked out the room. She was FAST. But she was sweet too.

A coworker called me from the other nurses station on the same floor but other side of hospital. (I did not even know she was gone)The pt remembered she was in room 40 but that she was looking for her friend on the floor above (there is no floor above us).

I met them half way and the pt was just talking up a storm to my co-worker.

Luckily the trip made her tired and she slept the rest of the night in bed.

Scared the bejeezus of of me.

She got a bed alarm after that. But only helped partially. If you were not there to see her then she could be gone before you got to the room. A sitter was not available.

I swear to the heavens that you just described an incident with my MIL in acute care. :)

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Specializes in Developmental Disabilites,.

Happened to me too. I had a pt who had a central line in that decided to go home for a shower and change of clothes. She lived around the block and thought that it was no problem. I was freaking out but thankfully security did a good job of canvassing the area. We found her in the cafeteria about 2hrs later where she stopped to get a treat before going back to the room. Her family was with her and no one could understand the problem. What a mess, not to mention her antibiotics were late.

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Specializes in Gerontology.

We have an entire process at our hospital for this exact thing - and yes, I've had it happen to me.

we call it Code Yellow.

1st stage - pt is paged to return to unit, unit is searched.

15 minutes is permitted for this stage

2nd Stage- over head accouncement - Code Yellow Phase. Discription of pt sent to every hosptial printer. Entire hospital searches for pt, each area had to report in to the unit involved. This includes a grounds search.

15 minutes permitted for this phase.

3rd Stage - Police are called. Neighbouring nsg homes are informed to be on the look out. This has no time limit - stays in effect until pt located.

We've had several "horror" stories of missing pts. One went to the bathroom and got in bed with another pt. The nurses didn't notice because she was small and tucked in next to a large pt. We found another one in the morgue - no one knows how she got in as that door is suppossed to only be able to be opened by security. She was only found because a porter came to the nsg station and said "he saw a ghost entering the morgue". Poor guy. They found the pt, with her walker trying to find a place to lie down and c/o that she was cold.

I could also tell you the story of how I "lost" my Mother (who had Alzhemier's) in Cuba but perhaps that's left best for "my worst nightmare" thread!

If there is reason to believe that the pt has left the grounds, Phase 3 can be jumped to immediatly.

Its a good system. It lets everyone know that a pt is missing and everyone keeps an eye out.

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Specializes in Certified Med/Surg tele, and other stuff.

Yeah, a herion addict decided to leave because we weren't giving him medication. A nurse went to take care of her other patients and she found him gone a half hour later. The cops found him a mile from the hospital with no shoes, and wandering. Since he was of age, he could do what he wanted. They did take him back to ED to get the IV out though.

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