I feel like I caused a patient's death and I can't get over it

[jane82]

I am a new nurse working in a sub acute rehab facility/LTC. I am typically assigned to care for 28 to 40 patients on midnights. I have been trying to get into a hospital but not having prior experiance or a BSN forced me to accept this job for experience. I have been concerned from the being with patient safety and the patient load I have.

Awhile back I had a patient whom I was not familiar with. She had a trach site, on O2, with continuous tube feed, and a mental illness condition. Later the CNA said she told her she was having difficulty breathing. So I checked her spo2 I raised the HOB from 30 to 45 degrees and increased her o2 and the sp02 increased. I notified the doctor on call.

When I later entered the room I noticed the patient looked really pale and asked if she was ok, the nurse replied "no she isn't, get a suction machine". I was in a panic, I thought "should I have suctioned her ?!?" I ran out to the find someone who knew where suction machine one and was told that there was one on the crash chart so I grabbed the crash chart and ran toward the room. When I came closer to the room someone said it was a code and to announce it on the overhead.

I feel like I did not do all I could for her and I have been crying almost daily because of it. I even started smoking again after quitting 6 years ago. I can't sleep without sleeping pills and I see her pale face in my head over and over. I would love some honest opinions from more seasoned nurses on this event because I feel so horrible about what happened.

[Elle23]

I made my fair share of mistakes as a new nurse, and it was only by the grace of God I didn't kill someone.

As difficult as they are to have to go through, those circumstances are a major way that we learn and grow as nurses.

Each and every mistake I made matured me and made me a much stronger and more vigilant nurse. And I certainly never, ever repeated those mistakes!

To the OP, accept this as the great learning opportunity that it is. As someone pointed out, you will be better equipped next time you encounter a trach patient by what you have learned.

[jtmarcy12, BSN, RN]

Oh my, there are so many things I want to say on this matter......

You contributed to this patients death. Allowing the family believe that it was the hospitals fault for discharging this patient too soon, when in actuality it was you and your facilities negligence for not providing proper equipment and training to its staff.

You stated the pt was sob so you raised hob to 30-45 degrees and increased 02.if this pt was on a continuous feed, their head should have already been elevated to those degrees.

When the pt asked for water but you refused because they are nectar thick liquids only. You should have nectar thick water provided for you and if not there should be the thickening packets so you can make your own nectar thick liquids.

If you didn't think it was a "safe" patient load you should have spoken up.

None of what I'm saying here is going to make you feel any better and it's not intended to. There are serious things that you, other staff and your facility did that contributed to this pts death.[/quote)

MATTHEW 7:1 SAYS JUDGE NOT LEST YOU BE JUDGE, THE JUDGEMENT YOU USE WILL BE MEASURED BACK TO YOU:

[mushyrn, BSN, RN]

I started my nursing career in a rehab/subacute facility much like you describe, except I was on days with 20-22 patients to "care" for. I left after 3 months because it is unsafe, and got a job in home health. Now a little over a year later I'm working on a medical-surgical unit in a hospital, and there is SO MUCH MORE support in the hospital than in rehab. It's dangerous in rehab. You did not cause that patient's death. The entire rehab "system" contributed to the death of that patient because it is very disturbing and unsafe as these patients are d/c way too soon in some cases from the hospital to you. And that patient, in all honesty, was just being kept alive it seems. She was ready to go.

Don't blame yourself. Try to get into home health or some other area of nursing. Rehab sucks. And work on the BSN. Nurses who haven't worked rehab don't understand how dangerous and ridiculous it is there. And those blaming you are being ridiculous as well.

[Carrie RN]

I think you need to settle down and breathe. Even with the proper equipment in the room, the patient still may have died. People die even when everything goes right. I think posters shouldn't be too critical as this should be a place for support which you obviously didn't get at work. I have in the past done post acute and long term care. I am curious why there was not a suction machine designated for this patient at bedside. This is an issue for the nursing manager to take up as there may be other potential patients that do not have necessary equipment in the room. I understand it is becoming increasingly difficult to handle patients in this environment without proper equipment and staff. This is an unfortunate learning experience, learn from it and move on.

[jane82]

I want to thank you all for the support, encouragement, and most of all advice. It truly means the world to me right now.

I feel the need to clarify a detail though based on your questions and comments.

The patient did not have an order for suction.

I do plan on still continue nursing and I will learn from this and all your advice and input. I just thought I should quit until I find a better hospital or facility. I have been applying at hospitals ever since I passed my NCLEX, but I think if I don't work, I'll have more time to look for work and less of a chance at a event like this one. My insurance just kicked in so maybe I’ll quit after I get a few therapy sessions in. I still don't know what I am going to do but I will defiantly renew my Liability Insurance that I had in nursing school for now. If anyone has a good company they would recommend I would love to research them.

I really want to thank everyone again for the support and input! I will try my best to learn, be better, and move on from this.

[NurseJoy33]

My thoughts exactly - suction equipment bedside is the proper set up. The facility is severely lacking, and you/your license are in danger by working there. Try hard to find another job even if it pays a little less. I left a better paying job for a lesser one due to issues that were threatening such as this. I never regretted it. Much to be said for piece of mind.

[jane82]

Want to thank you all for the support, encouragement, and most of all advice. It truly means the world to me right now.

I feel the need to clarify a few details though based on your questions and comments.

The patient did not have an order for suction. In report I was told it was an old trach site that was healing. She was getting 4L of o2 via nasal cannula. I didn't even know it was an open trach until I took the dressing off and changed it. Like I mentioned before I changed it due to the drainage. The opening was very small and it did look open but not like I have seen before (it was very small). When the EMT's arrived they intubated her through the trach and there was a lot of blood from them doing that, so it was partially healed. There was no collar or anything like that, just her skin and a dressing covering it. The lungs did sound congested and I logged for the doctor to take a chest x-ray and evaluate the old trach site. I didn't call the on-call doctor because I took a full set vitals twice and I checked her via pulse ox more time that I remember. I later talked to the admitting nurse about her and what happened and she said the trach was taken out 5 days before I had her (not sure how true that is). I was tempted to ask why she didn't get an order for suction or a suction machine at the bedside after knowing that, but I was afraid to admit my own guilt in the oversight.

I do plan on still continue nursing and I will learn from this and all your advice and input. I just thought I should quit until I find a better hospital or facility. I have been applying at hospitals ever since I passed my NCLEX, but I think if I don't work I'll have more time to look for work and less of a chance at a event like this one. My insurance just kicked in so maybe I'll quit after I get a few therapy sessions in. I still don't know what I am going to do but I will defiantly renew my Liability Insurance that I had in nursing school for now. If anyone has a good company they would recommend I would love to research them.

One thing that did bring up my spirits (other than these post) was a patient that was just readmitted that I sent out three weeks ago. Turns out my assessments where right and she had a pleural effusion and had 1500ml total removed via thoracentesis. She looked so good and thanked me for my help that night. There was an order for a bladder scan qshift also since she had a foley in the hospital that was just removed. She had 680ml from the scan so I straight cath. her. When I did that I noticed it was malodorous, dark and cloudy. The dip stick showed protein, ketones, leukocytes, and a high amount of blood. I will have to see what is going on when the lab comes back, but this was a good moral booster).

I have one more question in case anyone is still following this or cares to answer.

I had a patient last night who had a hip replacement with staples. He was a 50ish year old male with a history of diabetes and hypertension. When I was assessing the area I noticed the area surrounding the incision site just next to it looked like orange peel skin. I thought orange peel skin only had to do with breast cancer, but it really like it. The skin was more yellow than orange though. This entire leg was swollen, both pulses where present, cap refill was less than 3seconds. A previous nurse logged for a Doppler, it was done this morning and was negative for a DVT. He also had a low grad fever of 100.2. He was taken Norco regularly about every 4-5 hours so I think the acetaminophen in that may have been keeping a higher fever at bay. He said everyone including the doctor said his site looks fine and no S&S of infections. He also said it has looked like this for a while. I know he must be having a infection going on, probably cellulites, but I would like more info about the "orange peel skin" if anyone knows if it occurs in a soft tissue infection and what it may indicate, because the doctor looked at it again and said it was fine (the patient said the doctor looked at it again as long as it take to say his name lol). If it is nothing like the doctor said I'll let it go, but I just feel like it may be infected.

I really want to thank everyone again for the support and input! I will try my best to learn, be better, and move on from this.

[jane82]

Thanks, I think I may look into something like that because I feel scared now every time I work now. I have actually planned on getting my BSN even before going through the ADN program. I did it this way to save on cost and to start working sooner.In hindsight I think I should have just gone the BSN route, even though my school has a good reputation it seems like all hospitals are going the BSN route.

I'm I am enrolled in a RN to BSN program to start this January.

[RNlove17]

I've worked on a similar unit. They call themselves rehab/LTC but actually had pts with higher acuities who should still have been on a med/surg floor but they wanted to clear those beds so they would dump them on our unit. People were coding all the time on this supposed "rehab" unit, it was just a mess. The pt load of 28-40 patients is insane for 1 person to handle when it is NOT true LTC. Luckily I never had an issue like yours happen but it could have just been luck.I got out because it was just unsafe and I felt like I was putting pt's and my license in jeopardy because of that environment and culture. I know that is easier said than done when there are so few nursing jobs open to new grads.

Did you possibly contribute? Maybe. I don't know and it's hard to judge without being a fly on the wall and seeing the pt and your response. Some nurses who responded to you were pretty judgey based on only a few sentences you wrote. Apparently they are also the elusive "perfect" nurses. Listen, every nurse makes mistakes. I don't think you were grossly negligent or made a huge error, some of it sounds like realizing things were a mistake in hindsight. There should have been suction equipment already in there. How often do you have trachs? It may be that your unit needs more education on them, especially if you don't get them a lot (i know I would need a refresher as I never see them anymore at my current job).

What did the dr do when you informed them? To me, they majorly dropped the ball. Again on my old unit we would inform the HO of issues and they would just be annoyed and not want to come over, and ignored major issues a few times. You are not the only one who contributed. I would try hard to find another job, you are never going to succeed on a unit like this. You also need to speak someone, do you have EAP?

[jane82]

Thank you sugarcoma I really enjoyed reading this. I hope to get to the point you speak of where you can look at someone and just know when they are about to "crump". I know I should have done more but in the moment I thought I did well. I looked at her vitals instead of taking time and considering how the patient is reacting. I pray that this was God's plan as trite or as cold as that might sound.

I recently heard that this doctor won't deal with patients unless you really press him and the on-call doctor is a joke. He acts like you are the biggest a-hole for calling him in the middle of the night (that is if he even calls you back). I hear other nurses complaining and taking to management about the staffing, lack of supply, and resourcing issues. It's hard to know who you can go to because like you said "many nurses seem to love out-nursing their peers". This is a privately owned facility that revenues about 12millliion annually for building that holds approx 180 beds, so I don’t think they are hard up for funding (maybe I’m wrong but it seems like they are doing more than fine). The place looks really nice, but they are putting the money in the wrong areas for improvement.

I know I will find problems like this everywhere, but I know almost any hospital is better than this.

When I was still precepting a fellow nurse who is very good said "welcome to hell!”… I know I should have ran then, but I was too naive. I was just hopeful and excited to start my new career. I know I need a new environment, so I can take time to breathe and think critically (I have never taken a break on midnights, and I try not to drink too much because I know peeing takes time out of my shift, and if I eat it’s a protein bar as I chart).

I will end saying that I agree with what you and the other nurse said… sub-acute rehab is Hell!

[jane82]

I've worked on a similar unit. They call themselves rehab/LTC but actually had pts with higher acuities who should still have been on a med/surg floor but they wanted to clear those beds so they would dump them on our unit. People were coding all the time on this supposed "rehab" unit, it was just a mess. The pt load of 28-40 patients is insane for 1 person to handle when it is NOT true LTC. Luckily I never had an issue like yours happen but it could have just been luck.I got out because it was just unsafe and I felt like I was putting pt's and my license in jeopardy because of that environment and culture. I know that is easier said than done when there are so few nursing jobs open to new grads.

Did you possibly contribute? Maybe. I don't know and it's hard to judge without being a fly on the wall and seeing the pt and your response. Some nurses who responded to you were pretty judgey based on only a few sentences you wrote. Apparently they are also the elusive "perfect" nurses. Listen, every nurse makes mistakes. I don't think you were grossly negligent or made a huge error, some of it sounds like realizing things were a mistake in hindsight. There should have been suction equipment already in there. How often do you have trachs? It may be that your unit needs more education on them, especially if you don't get them a lot (i know I would need a refresher as I never see them anymore at my current job).

What did the dr do when you informed them? To me, they majorly dropped the ball. Again on my old unit we would inform the HO of issues and they would just be annoyed and not want to come over, and ignored major issues a few times. You are not the only one who contributed. I would try hard to find another job, you are never going to succeed on a unit like this. You also need to speak someone, do you have EAP?

No, they don't have an EAP. I never got a call back before the code. Which is not unusual, they seemed more annoyed when you go to them with problems. There is one pretty good doctor there, but he doesn’t have that many patients under his care.

This was the first trach I have seen there. I had one during clinical, during my Med surg 2 rotation over a year ago. I forgot though... I did ask another nurse that night who has been there for five years who also was one of my preceptors about trach care for a healing trach. He said he has only had one. I should have at least asked him to at least look at her since he is one of the very few who helps others, but I didn't think of it. He was on another unit and I only saw him in passing, if I told him what I told the nurse on my unit I'm sure he would have tried to help.

[LadyFree28, BSN, LPN, RN]

Wait...your employer does!'t have an Employee Assisted Program (EAP)??? So you can talk to a professional???

I would clarify with human resources just to make sure...even the most dumpiest places I worked for had EAP.