Incident or not?

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So tell me what you think about this. I need advice, I was a witness to what might be considered an "incident" tell me if you think it is or what you would have done.

Patient comes for ER, has a history of CHF, ARF, he's diabetic and his chief complaint was chest pain. He's suppose to be on 2L of O2 but somehow he got hooked up to the "room air" port... thus his 02 sat dropped to 83-87 so we called the doctor, he flips out orders a bunch of labs and wants him transfered to ICU, AFTER we call we go a notice that he's connected to the wrong port, change it over and he's back to 95% so we call the doctor back and he says fine and cancels all the orders. NOW, would you say harm was done to the patient?

Specializes in Education, FP, LNC, Forensics, ED, OB.

I must still say this patient was harmed. He arrived in the ER for chest pain warranting treatment of which O2 is essential.

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I must still say this patient was harmed. He arrived in the ER for chest pain warranting treatment of which O2 is essential.

You are right - I thought about it again and changed my mind. I'm thinking of our COPDers . ... .

steph

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So tell me what you think about this. I need advice, I was a witness to what might be considered an "incident" tell me if you think it is or what you would have done.

Patient comes for ER, has a history of CHF, ARF, he's diabetic and his chief complaint was chest pain. He's suppose to be on 2L of O2 but somehow he got hooked up to the "room air" port... thus his 02 sat dropped to 83-87 so we called the doctor, he flips out orders a bunch of labs and wants him transfered to ICU, AFTER we call we go a notice that he's connected to the wrong port, change it over and he's back to 95% so we call the doctor back and he says fine and cancels all the orders. NOW, would you say harm was done to the patient?

I guess I should clarify, the patient came to the ER and was TRANSFERRED to my floor, the ER people connected him to the yellow port, I guess inadvertantly (sp) because he had a LOT of "things" going on and I'm sure they were in a hurry, anyways, no, the patient was fine after he was switched over AND when his O2 sat dropped he was breathing fine still, in no respiratory distress, laughing and joking with his family... so we called the doctor back and told him he was okay and the doctor said to cancel all the orders that he wanted including the transfer to ICU. I guess no incident report was written, it wasn't up to me to write her up but since I witnessed what was going on I'd have to sign her report too.... but it's fine, that's for the advice!

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

Folks, the whole idea of an "incident report" is to examine a given situation, get those who need to be, involved, and problem-solve. In this context, anyone can see, an "incident report" IS indeed appropriate. Too bad, many places use "incident reporting" as a simply punitive process. NOTHING is learned thinking of it this way. I am afraid, in this case, an "incident report" is indeed appropriate. I just hope the handling of it is, as well, APPROPRIATE, involving all disciplines to "fix" this problem, so it does not occur again.

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Specializes in Clinical Research, Outpt Women's Health.

It does warrant an incident report so that proper education can be done for the staff involved, and perhaps a review for all to be aware of this, and prevent it happening again. There should not be any punitive action.

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Specializes in Gerontological Nursing, Acute Rehab.
Folks, the whole idea of an "incident report" is to examine a given situation, get those who need to be, involved, and problem-solve. In this context, anyone can see, an "incident report" IS indeed appropriate. Too bad, many places use "incident reporting" as a simply punitive process. NOTHING is learned thinking of it this way. I am afraid, in this case, an "incident report" is indeed appropriate. I just hope the handling of it is, as well, APPROPRIATE, involving all disciplines to "fix" this problem, so it does not occur again.

:yeahthat:

Other staff members shouldn't even be involved in this decision. Bring it quietly to you manager and let her handle it. Since you found the error, you might have to write up the report, but other than that, leave it in your managers hands.

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