How does inadequate staffing relate to patient safety? Any stories?

RN1982 · Jan 30, 2009

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Midwest4me · Jan 31, 2009

Oh TraumaNurse that is such a sad story! I was struck by one thing though: is there not a nurse stationed at the front desk MONITORING the central monitor? I can only imagine the investigation that ensued and will bet that the hospital laid blame for the pt's death on his nurse---which of course is unrealistic in my mind since you said management was given a heads-up on the need for a sitter.

RN1982 · Jan 31, 2009

Actually, at the time, no there was not anyone monitoring the central monitor. CMS came in to investigate because the patient had died in restraints and said that we had to have someone watch the monitor or else. So after that yes, there was someone monitoring the central monitor. The nurse was of course, devastated when this happened. They had to code the patient. She was not found at fault. I had worked with her many times, she's a very good nurse. This really could have happened to any of the nurses on the unit.

Pediatric Critical Care Columnist · Jan 31, 2009

No one watches our central monitor either. I'm not sure why we even have one.

On our unit, we are expected to cross-cover for breaks in a level 4 PICU where in recent years the majority of our hires have been new grads who in turn were precepted by staff with less than a full year of experience. This cross-coverage very often results in critically ill post-cardiovascular surgery patients covered by nurses who are not qualified by our unit's policies, or cross-covering patients who are supposed to be 1:1 by policy. There are times when one nurse might be responsible for 4 infants all on pressors, with intracardiac lines, and a host of other factors. We rarely use neuromuscular blockers so the odds of one or more of these little people getting into trouble at the same time is high. I could cite many instances of unplanned extubations, loss of central and arterial lines, monitor alarms going ignored for several minutes, and other such consequences of inadequate (or inappropriate) staffing.

But one instance jumps to mind. I was not there when it happened but someone whose credibility is unquestioned was. Her patient was a child with chronic serious health problems, trached on CPAP and prone to seizures. He had come in with sepsis and was starting to rally. She went for her supper break, leaving the nurse at the next bed to cover him. When she returned to the unit, she discovered that her patient was now on a rate. She asked her break nurse what happened and the nurse told her that he had gone apneic not long after my friend had left the unit at least half an hour previously, so the RT put him on a rate. Her next question was, "Why did he go apneic?" and the response was that the other nurse didn't know. "Well, did you assess him?" "No, I was busy changing the linen for my patient so the RT just bagged him then put him on a rate." When she assessed her patient his pupils were blown. He was also bradycardic and hypertensive... A stat CT showed a massive intracranial bleed and incipient herniation. The boy died hours later. My friend was livid; this wasn't the first time something like this had happened with one of her patients while she was on her break and in short order she quit.

RN1982 · Jan 31, 2009

Oh lordie. Thats very sad. The nurse who covered your friend's break was very lazy. That's why I hate taking a break sometimes depending on who I am working with. If I have the good co-workers who will do anything for me, I will take a break, if I have co-workers who I know are lazy and they won't peek in on my patients while I am away, I don't take a break.

schroeders_piano, RN · Jan 31, 2009

I understand these stories. I worked an ICU once that staffing was 2 RNs period. That would be good staffing for a small ICU, but we had 11 bads. You can just imagine some of the stuff that happened.

Not_A_Hat_Person, RN · Jan 31, 2009

In interviewed at a hospital. I thought the nurse-patient ratio was high (ex. 1:10 nights on a med/surg/ortho unit). About a month later, at a different hospital in the same system, a woman with dementia and heart problems wandered off of the unit and ended up dying on the roof.

Pediatric Critical Care Columnist · Jan 31, 2009

Oh lordie. Thats very sad. The nurse who covered your friend's break was very lazy. That's why I hate taking a break sometimes depending on who I am working with. If I have the good co-workers who will do anything for me, I will take a break, if I have co-workers who I know are lazy and they won't peek in on my patients while I am away, I don't take a break.

I don't think the nurse covering her break was lazy. I think the nurse was unequal to the task of caring for two critically ill patients at the same time and lacked the ability to "see" the situation because she had no nursing experience at all other than a few months on our unit. And this nurse didn't have to "look in" on my friend's patient, she could see him from where she was doing her linen change. She just didn't get it that he shouldn't be apneic or that Cushing's Triad was a bad thing. "Cushing's Triad? Never heard of it."

I often find myself assigned to a rock-stable patient down at the far end of the eight-bed open ward area of our unit with three shiny brand new nurses who have been off orientation all of five minutes. I know I've been put there by the charge nurse to make sure all four of those kids are still alive at the end of the shift. I know this because the charge nurse has told me so. "I don't have to worry about this end of the unit because I know you'll make sure everyone is safe." That kind of responsibility gets old after awhile.

mskate · Jan 31, 2009

an one hospital i worked at, their step down unit had 1 separate patients die from brain bleeds after falling out of bed, nurse unaware d/t staffing complications.

truern · Jan 31, 2009

She just didn't get it that he shouldn't be apneic or that Cushing's Triad was a bad thing. "Cushing's Triad? Never heard of it."

Cushing's Triad was the ONLY knowledge-based question on my NCLEX-RN. Tell's me it's VERY important to know!

Pediatric Critical Care Columnist · Jan 31, 2009

Cushing's Triad was the ONLY knowledge-based question on my NCLEX-RN. Tell's me it's VERY important to know!

It seems to me that it was covered in our unit-based orientation too, but she couldn't put the pieces the patient was displaying - bradycardia + hypertension + apnea = very bad scene - together and come up with it. Our orientation is rushed, it's shallow and the hands-on experience they get is inappropriate. The assignments are not made based on what the new nurse needs to learn but on what the unit needs from the preceptor. If I, as one of our most senior nurses and perhaps the only one on for a given shift, had an orientee and there was a crashing kid onthe unit, that would be my assignment and the orienee would spend the shift observing. But by the same token, if we hired a very experienced nurse from a PICU in a hospital in another city, that new nurse would be treated like s/he was green as grass and not advanced as quickly as s/he deserves, because they have to go by seniority! It's dumb.