Multi-shift problem discovered during hand-off.

[dudette10]

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?

[hiddencatRN, BSN, RN]

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.

Second. Don't borrow trouble. No harm came to the patient and you CAUGHT the error. I like the suggestion to do an analysis to find out what processes can be changed to prevent future errors, but I wouldn't stress over this.

[caliotter3]

On more than one occasion, when hospitalized, things were discussed and promises were made to me (the patient), that never happened before my discharge. I would like to think it was a good thing that I wasn't insistent, or argumentative, or demanding. But what got me slightly perturbed was the quick excuse without the bat of an eye if I questioned the situation. Nobody acted as worried as you seem to be about something that really was not your fault. Chill out.

[wooh, BSN, RN]

With as many people involved as there are, all with way more to do than time to do it in...

Quite honestly, I'm surprised things go RIGHT as often as they do.

[StrwbryblndRN]

I had something similar recently. Pt had an order to restart home meds after NG tube out. Days passed and the pt mentioned her home meds after the tube came out. I sat down and went through many orders to find it.

Unfortunately our med system does not have good communication regarding conditional orders.

[Jolie, BSN]

I agree with the poster who suggested doing a root cause analysis, much like a med error.

For one of 20 nurses involved to take the sole responsibility for this test being missed makes about as much sense as firing the nurse unfortunate enough to administer a mistaken dose of medication that has passed thru the hands and heads of 20 people before him/her.

Thank you for your conscientiousness, but you don't deserve the hit for this.

[germanshep]

Nursing is 24 hours a day, 7 days a week. Things get missed. Thank goodness the patient is ok.

[Minnie2006]

It was discovered and addressed. You did your part correctly. No harm came. Unfortunately there is barely enough time to keep up with what changes with one shift let alone many. Do your best that's all you can do. Nursing is a team effort 24/7.

[dudette10, MSN, RN]

The worst thing you can do is take responsibility for problems you aren't responsible for.

This is funny...

For the second thing, I did take responsibility, but as I was investigating it further in the computer, I realized that it was also a multi-shift problem. I was able to correct it though.

The doc about had a freakin' seizure, metaphorically speaking. As I left, he saw me, and he was much nicer about it now that it was fixed, but I never told him that it wasn't really my fault.

As he was talking to me, he kept staring at my name tag.

Funny how some docs don't give two hoots what your name is until they think you've done something to screw them over.

[elprup, BSN, RN]

I bet he was checking your name because he wanted to remember you as being the one who took it upon herself to actually fix the problem instead of passing the buck.

[Jolie, BSN]

[quote=dudette10;5821461As he was talking to me, he kept staring at my name tag.

Funny how some docs don't give two hoots what your name is until they think you've done something to screw them over.

Some day, you'll save his sad behind. Made darn sure he knows your name then!