Near miss, should I be blamed?

[Tony35NYC]

This week I got in trouble for a near miss. Well... myself, the secretary, the PCA, and the nurse I took report from. We were all written up for it, but I was told that it was primarily my fault. This is a long post, but for anyone who has the time to read it, here's what happened:

I was floating to PCCU and this particular patient was a fresh post-op open heart who had been transferred in from CVICU a bit early because they needed the bed. In my opinion, this patient should not have been moved from CV because he was still very unstable, on multiple drips, still had respiratory issues, still retaining a lot of fluid from the CHF, and had two lateral and one medial chest tubes draining sanguinous. He was NSR on the monitor but he had had 5 bypasses, and he came over with the pacer set at 50/20. The agency nurse who gave me report on this patient neglected to tell me quite a few important details about this guy. She was very angry and in a bad mood because she had had a very rough shift. All her assignments were pretty complicated cases, she kept complaining that she had to be literally running from one room to the next the whole time and how she couldn't wait to leave and that she was never coming back to work on this unit.

A number of things were strange about this whole event. First of all, the hospital has a policy to not give fresh open heart patients to agency nurses, but in this instance they did because they had no one else. As I would later find out, this particular nurse did not have any experience with cardiac patients and she did not follow some of the post op protocols (which later caused problems for me)---and more serious problems for the patient. The other thing is that PCCU has a policy to not give more than three assignments to a nurse who has fresh heart patients, especially when they are on titrated drips, but in this instance, they gave the nurse six assignments, and she apparently did not know that she should have refused. In my opinion, they shouldn't transfer any post op heart patient who's on titrated drips to stepdown because they need much closer monitoring than you can give when you have three or more other patients to take care of.

During report, she told me that the patient was stable (which was not true), that his surgical dressings were dry and intact (which was also not true), that his o2 sat was good (which was also not true), and that all his drips had been D/C'd except for a bag of LR which was going at 75cc/hr. I was to take over all her other assignments as well, and I spoke to the charge nurse about this because I didn't feel comfortable about having six patients and a fresh heart. Her response to me is that we were really short on staff, and since the patients are all stable we would play it by ear and she would try to make some changes if anything develops. My first big mistake was to agree to this. Under any other circumstances I would have refused the assignments and gone back home, but she warned me that I had already taken report and that if I left she would write me up for pt abandonment.

Only a few minutes into the shift, one of my other patients went asystole and we had to rush in there to run a code. Fortunately, we were able to bring the patient back, but by the time we stabilized the patient and moved him to the ICU I was nearly 2 hours behind with my assessments and chart reviews.

By the time I got around to doing my assessment on the open heart patient (who I decided to see first) I immediately realized that this patient was also going bad. The respirations were labored and I could hear the fluids on his lungs even without using the stethoscope. The continuous pulse ox monitor was still attached to his finger but the machine was off (it was not plugged in and the battery had died). He was supposedly on 5 liters of 02 via NC (which wasn't even humidified, by the way), and when I got the oximeter on again his sat was 80, and only God knows how long it had been there. (The nasal canula he was supposed to be wearing was on his forehead). Ok, so I rush to get the respiratory issue under control (called in RT, etc.). RT eventually had to put a nonrebreather on him, and protocol states that if a patient is unstable enough to need a nonrebreather they must be transferred to ICU. The guy was still not doing so good, and the anesthesiologist from the respiratory ICU was seriously contemplating putting him on a vent, but thankfully, that wasn't necessary. Of course, after I notified the MD and began to prep the pt I was told that there were no ICU beds. In emergency cases such as these, PCCU is supposed to implement ICU protocols and we had the equipment at hand so that was done. But, here's another big problem: ICU protocols have been initiated, but I still have six patients, and neither the charge nurse or the nursing supervisor is returning my calls because they are too busy fighting fires with serious staffing and other issues elsewhere.

Then I start to check out other things on the pt. The dressing on his chest was soaked through and it turned out that the guy had frank, active bleeding from the sternotomy. Applied some pressure to the site, reinforced the dressing and put out a call to the surgeon. But it didn't end there. The guy was also a new onset diabetic with hyperosmolar issues. I immediately went to check the blood sugar because he seemed confused and aggitated and I suspected that the blood sugar might be low because he had been on an insulin drip (which the nurse had told me was DC'd). An order had been written to D/C the insulin drip and switch the pt to a sliding scale with regular insulin and to change him from LR to D5 1/2 (neither of which had been implemented), according to the MAR and the diabetic flow sheets the nurse from the previous shift had been doing the blood sugar checks AC & HS instead of Q2 according to the protocols. Even though the MD had incorrectly written the order for AC and HS she should have known better because the patient was still NPO so an order for AC BS checks makes no sense. Furthermore, the insulin drip protocol overrides written orders for BS checks in all the units. The guy's BS was in the 30s so I immediately shut off the drip and pushed D50. He was also complaining of pain, but I didn't want to give him any narcotics right then because of the respiratory situation.

And, it gets worse. When I went to check the BS, I found that the patient was not wearing an arm band so there was nothing to scan into the glucometer. I eventually found the ID band and the blood arm band on the window ledge (he had been type and screened for blood and he needed 2 units to replace blood loss during surgery). I later found out that the nurse had cut the bands off because his previous IV site had infiltrated and his arm had swollen up so much that the bands were too tight. Yes, she did order new ones from admitting, but when they sent them up she grabbed the wrong ones from the nurses station and put them in the patient's room. So, in my haste to scan the arm band to check the BS I didn't immediately notice that it was the wrong patient name. She also did not give the second unit of PRBCs that was ordered. Thank God, I caught the mistake with the wrong blood ID band during the ID check for the second transfusion otherwise I would have transfused the wrong blood type, and the poor guy probably would not have survived a severe reaction.

The pulmonologist ordered diuresis with 80mg of IV lasix stat. When I went to give it I realized the guy did not have a foley in. How could you have an unstable surgical pt like this in a critical care unit with no foley? I began to wonder where she was getting the information she had been recording as his urine output on the nursing assessment sheet, then I figured she must have made it up because this guy was certainly in no position to use a urinal. Furthermore, the urine output she had recorded could not have been correct because if this guy had been NPO and receiving only 75 ccs of IV fluids an hour and putting out that much urine over the past several hours there's just no way he could still have so much fluid on him. Also, when I checked the post op orders I found that his AV pacer had been incorrectly set. And here's another big one: remember the drips that she told me were off? Well, not so! The guy came from CV on a titrated nitro drip, and not only could I not find any information on the flow sheet to prove that she was titrating the drip but it was actually still going @ 5 mics, which is exactly where it was set when he was transferred from CV hours ago. Also, the PCA who did the vital signs did not tell me his BP was critical low, in fact, I couldn't even find her! When I checked it myself it was 60s over 40s.

There were so many other things that were either not done or done incorrectly that by the time I got around to checking and fixing and assessing everything to prepare to send the patient back to the OR it was now almost 3 hours into the shift and I hadn't yet seen any of my other patients (except for the code) and all my meds were passed very, very late. I don't know what I would have done if one of the other patients had crashed that night. I could just imagine myself explaining to the board of nursing why I had not done any assessments on my other patients after being on shift for more than three hours!

Of course, an incident report had to be done, and administration is saying its primarily my fault because I should have done my initial assessment on my fresh heart patient sooner. I accept some of the responsibility, but I disagree that it was my fault. How do you rationalize switching priorities from responding to a code situation if you are made to believe in report that your other patients are stable. Also, why are they trying to throw all the blame on me when they are also at fault for giving this patient to a nurse with absolutely no critical care training or experience in the first place? Also, the charge nurse later denied that she and I had had a conversation about changing asssignments according to patient acuity. She instead said that I failed to show good professional judgment because I should not have accepted the assignments in the first place. I realize she was covering her butt, but I think its disgusting that she just flat out lied like that. Instead of looking at the whole picture and talking about how to prevent something like this from happening again, the whole incident deteriorated into one of fingerpointing and accusations. If this patient had died its obvious they would have tried to pin the whole thing on me. They would still have their hospital, but its very possible that I could have had charges brought up against me, that I could get sued, or that I could even lose my license.

Now I don't trust anyone when I take report. Perhaps some of you could tell me what I could have done differently.

[Drysolong]

This week I got in trouble for a near miss. Well... myself, the secretary, the PCA, and the nurse I took report from. We were all written up for it, but I was told that it was primarily my fault. This is a long post, but for anyone who has the time to read it, here's what happened:

Now I don't trust anyone when I take report. Perhaps some of you could tell me what I could have done differently.

I did take the time to read your entire post and it was so scary to me. One reason is because I'm a recently graduated LPN student with no prior nursing experience and the knowledge I have doesn't come close to even

being able to visualize caring for a patient at this serious level.

I had a similar (but much less traumatic) experience in clinicals, when taking report from the night nurse who claimed she had just changed a patient's dressing. Even to me, a student nurse, it was so obvious that this patient's blood-soaked dressing could not have been just changed.

I guess I only have more questions. How much can you trust someone else's information? (i.e., CNA, PCT previous shift's nurse) How do you not accept an assignment? I've gathered that one should inform the charge nurse that the assignment is not safe (with a witness). Is this enough?

Are there ways to verify that the report you are getting is accurate without actually seeing the patient?

Tony35NYC, your post has been an eye-opener for me on what can happen in our field.

[DusktilDawn]

I think you did the best you could in a very bad situation that was definately not of your making. I honestly don't know what you could have done differently, except to question from the get go why this nurse you received report from had 6 patients in a critical care area.

It sounds like this patient should not have been transferred in the first place from CVICU. I understand the PCA catching heat for not reporting the VS, and also the agency nurse for the inconsistencies with her report to start with. I don't understand why the charge nurses judgement isn't being called in to question over the assignment she gave or why she didn't assess your situation when you spoke with her about and in regards to hospital policy about not giving this particular type of patient to an agency nurse. Also why would a nurse with no critical care training be assigned and accept assignment to an area that she wasn't qualified to work and than give her a patient assignment that was inappropriate, even for someone with critical care training/experience.

Instead of pointing the finger of blame towards you, it needs to be determined why this whole situation happened in the first place, starting from this patients transfer from CVICU. I also don't understand why the secretary is being blamed.

[smk1, LPN]

wow! i have no nursing advice to give because i am just a student, but perhaps you could try to get a policy of taped report so that you have proof of what was said in report, and also get a policy going where anytime a nurse wants to speak to the manager about acuity levels and too many patients, then a report should be filled out and cc'd to risk management, supervisors etc.. this might stop the supervisors from lying about conversations that took place.

[VivaLasViejas, ASN, RN]

This has to be one of the most egregious cases of hospital understaffing I have ever read.

The only thing that you did wrong here was to accept the assignment and take report in the first place.

All I can say is, document, document, document---print out and keep a copy of this thread, and write a more detailed record of each and every thing you did or did not do during that shift NOW, while it is still fresh in your mind. Also make a note of what was NOT said at report, and what was different from the report you were given. Use room/bed numbers and initials instead of actual patient names, and keep this record in a safe place, such as a locked drawer or a fireproof lockbox, in case you ever need to prove your case in a court of law.

Good luck to you, and if you learn nothing else from this experience, I hope you know now that you should NEVER accept any assignment you believe to be unsafe. I don't care if the President of the United States threatens you with fake charges of abandonment, or says "you'll never work in this town again"---he won't testify for you when you stand in front of a judge or the Board of Nursing trying to explain why you failed to do such-and-such for Patient So-and-So.

[limabean]

Oh my gosh....I thought I had it bad sometimes!!! I have never heard of anything like this happening on a stepdown unit! I dont know what else you could have done, except maybe have another nurse check on your other patients while you were running the code. But hey, it looks like nobody was really willing to help much at all. I definitely dont think it was your fault. No matter how much training the nurse before you did or did not have, there is no excuse for that much misinformation in a report. Something needs to be done about that! I am amazed at the number of things that were compeletely wrong with this patient that she did not pass on to you. It is almost like she gave you report on another patient! Thank God the open heart patient had a nurse like you to take care of him, otherwise the hospital might have a major lawsuit on their hands and more importantly a patient might be dead.

[leslie :-D]

i was just going to post what marla said: document, document, document.

why would you even consider refusing an assignment if you received a FALSE report of pts being stable????

you need to tell your story tony. don? risk mgmt? qa? and i hope you did write a very detailed nurse's note on your post-op pt....including all of your findings. and on the incident report, your conversation w/the charge.

i can't think of anything more deplorable....for the pts and staff.

perhaps it's time to find a safer place to work.....

leslie

[hrtprncss]

This is so bad for the patient, and for you.... The CV surgeon needs to have an inservice for the staff on that unit, with the manager and charge nurse present. Staffing issues needs to be addressed. I read the entire post, and I couldn't even keep up with all the bad things happening to that patient......quick question though, u said the patient was due to receive a second unit of blood but you didn't give it which is good because the patient had the wrong armband, does this mean the patient got the wrong first unit from the agency nurse, and the patient went into hemolytic reaction? just wondering cuz of the bleeding, hypotension and resp distress?

EDIT: Sorry I'm just confused about the blood orders, I prolly read it wrong.

Sorry I wanted to say and this is important, that your nurse manager from your own unit HAS to back you up. As soon as you have an unstable patient and your other patient goes up and code and there's no ICU bed, that means YOU HAVE TWO ICU PATIENTS and you have a full load. The four other patients didn't get the care they deserved and this was not your fault. You have to talk to your nurse manager, that unit was in the wrong. You are putting your license in jeopardy and they are covering their butt...You said you were trying to contact the Charge Nurse, and she was in the middle of staffing issues...SHE SHOULD HAVE BEEN AT THE BEDSIDE HELPING YOU, THERE'S NO EXCUSE...That's a charge nurse responsibility, and even if the charge nurse had her own patients, she shouldn't have accepted this staffing ratio to begin with. Sorry if this is sounding a little harsh for any charge nurses out there, but I'm just being a patient and a staff nurse advocate.

[bahamabread]

My Gosh! It was like reading many many of my shifts. I have had so many days like that its unbelievable. Management doesnt CARE!

So one day,,,,,,,,,Im fed up and I put the patients first and I refuse to recieve another pt!!!!!!!!!!! REFUSED!! I said " ILL GO HOME!!" So what happened? The manager puts the patient in the bed and leaves it for me. SO I LEFT 1/2 hr before my shift end!! ( of course I did everything before I left and everyone was stable!!) I was trying to prove a point after talking and talking and letters and letters was doing nothing. So what did I get ? Of course almost fired,,,,,,,,,,and had to answer for my liscence.

Want to know the twist? This wasnt the United States and I had 12 pts handed over to me that shift.....one on a ventilator!! But I had 14 beds and the policy is to fill the beds regardless of what type of cases you have. I was 7 months pregnant and had only a (LPN) and an aid to help.

OK........... if I took the pt willingly and anything happened to any of my pts,,,,,,,,,,,,,,,,,they would have said,,,,,,,,,,,,,,,," YOU HAVE TO LEARN TO PRIORITIZE!"

My dear, your story is not unusual. Happens everywhere. You know what I learned? If I can go home,,,,,,,,and lay down and sleep well KNOWING I did everything I could do,,,,,,,,,,,I AM HAPPY AND CONTENT!

They get you no matter what you do. Its all about saving thier necks.............and the poor RN gets all of it dumped on her and she's the only one doing all of the work!!!!!!!!!!!!!!!!!!

[SJERNBSN]

When I worked in the ICU, I would take report from the offgoing nurse in the break room or nurses' station then we would both walk to the patient's bedside and do a quick overview of the IVs, dsgs, tubes, settings, etc. That way anything said to you in report could be verified and you could get a look of each of your patients. That helped me to prioritize my own schedule for my assessments when the other nurse left. Anything out of the ordinary could be questioned and anything off-kilter could be corrected by the off nurse.

It takes time but when the offgoing nurse knows that it is expected of her, the oral reports tend to be factual and less chatty and the patients look better than if the staff knows that they can run out before you can look at what they've left you.

Get another job. The administration will hang you before they'll admit that they try to abuse their staff. That's abuse of staff and patients, too. Leave before they chip away at your self esteem. You sound like a knowledgeable, caring, astute nurse - the kind the profession should be trying to keep, not harass.

Good luck.

[Ahhphoey]

I have never heard or read of anything this dangerous or scary in my career! Like everyone else said, document thouroughly and CYA. I can't imagine having this patient along with five others to care for. He definitely sounds like an ICU patient that should have never left ICU in the first place. I understand that it is the doctors choice to transfer a pt, but it is in my experience that the docs talk with the ICU nurses to really judge if that pt is stable enough to fly out to the floor. If I were the ICU nurse, I would have questioned transferring this patient to step down. Either way, this patient really just fell through the cracks. I am sorry that you had to be put through such a horrible situation.

[pricklypear]

i was just going to post what marla said: document, document, document.

why would you even consider refusing an assignment if you received a FALSE report of pts being stable????

you need to tell your story tony. don? risk mgmt? qa? and i hope you did write a very detailed nurse's note on your post-op pt....including all of your findings. and on the incident report, your conversation w/the charge.

i can't think of anything more deplorable....for the pts and staff.

perhaps it's time to find a safer place to work.....

leslie

Absolutely agree w/ leslie. I wouldn't work in a place like that for 1 more minute. It sounds like a nightmare. You appear to have a good head on your shoulders, and excellent skills - they would be better put to use somewhere where your license isn't in danger everyday. Good luck.