Multi-shift problem discovered during hand-off.

[dudette10, MSN, RN]

God, I feel sick.

Has anyone ever encountered a multi-shift problem (multi-day, even) discovered at the end of your own shift? I followed hospital policy on the chart checks, so there was no way I could have found the problem without going back days.

I still feel sick to my stomach because I was the one who was responsible for these patients immediately before the issues were discovered.

It was a care coordination problem, not a med problem or anything like that. No harm could come to the patients with the errors discovered. So, that's good. But, it really was a screwed up situation. Everyone, literally everyone, was irritated.

I'm new, and I feel incredibly responsible, although I'm trying to move on. Words of advice on how to prevent it in the future or to be able to shake it off?

[vanburbian]

Can you provide a detail or two, and maybe one of us can give you a suggestion to prevent future similar "problems".

[loriangel14, RN]

S***t happens.Don't feel like it was all your fault and don't be too hard on yourself.Without knowing exactly what happened it's hard to give advice on how to keep it from happening again.

[SweetheartRN]

its kindof hard to give you good feedback without knowing more about the specific situation but with days and days of chart checks completed its hard to catch something that was never done/initiated especially if you havent had that patient at all or frequently during their stay. Basically people are falliable and the only way you will know for sure is to check each chart from the beginning (admission/transfer) to now. And we all have time for that right?

[elthia]

Yes, I have found problems like that before. It is upsetting to me every time. I usually make it my practice to go back as far as I possibly can on chart checks as I possibly can when I have the time. I would suggest discussing with your NM or your Unit Action Committee about starting a root cause analysis to get to the bottom of the situation to prevent future errors of the type. If you approach the situation about being proactive in preventing future errors instead of reactive about the current error, you might feel you have accomplished something.

[samirish]

I still havent found out exactly what your talking about. So I am unable to give you any advice.

[dudette10, MSN, RN]

A procedure that was supposed to happen days ago kept getting put off, it was rescheduled, the reschedule was never communicated (not sure how that happened), and very recent orders prevented the patient from going to rescheduled procedure. Talk about messed up.

I said that no harm could come to the patient in question because there was no way a nurse was going to let the patient off to the procedure considering the recent orders.

I can't think of a way to vaguely give info on the other issue.

[Cat_RN, ASN, BSN, RN]

A procedure that was supposed to happen days ago kept getting put off, it was rescheduled, the reschedule was never communicated (not sure how that happened), and very recent orders prevented the patient from going to rescheduled procedure. Talk about messed up.

I said that no harm could come to the patient in question because there was no way a nurse was going to let the patient off to the procedure considering the recent orders.

I can't think of a way to vaguely give info on the other issue.

The worst thing you can do is take responsibility for problems you aren't responsible for. The job is stressful enough and it is never a perfect science. This type of thing is far more common than you're aware of yet.

[SuesquatchRN, BSN, RN]

Yup. Stuff happens. I once discovered a multi-shift problem that involved a med and could have caused harm. Actually, one of the floor nurses discovered it when a lab result was questioned. We immediately went back to the beginning of the order change to see how it flowed through so many shifts and so many checkpoints. Once we did we wrote a new procedure and brought it to the ADON who immediately implemented it. It was a perfect example of how med error reporting should be used - not as punitive, but for root cause analysis.

[loriangel14, RN]

Hey sometimes stuff gets missed.

[merlee]

So ultimately no harm has come to this patient, and the communication was not missed on your most recent shift. Do not take responsibilty for things that 'may have happened'.

Take care, and best wishes.

[corky1272RN]

Is there any in-facility form that can be filled out, like an incident report? You may not be able to do anything about this particular incident that happened but if you bring it to the attention of management it might not happen again. At my facility there is an online form, management will investigate, it could be an ongoing problem with a certain nurse or something else.