Near miss, should I be blamed?

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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.

Specializes in Day Surgery/Infusion/ED.
DEFINATELY put in your notice, meet with the hospital administrator and discuss your concerns. Have them read a copy of the first post you posted on here. Let them know that you have been a dedicated nurse and that the conditions are unsafe. Explain the charge nurse's actions and then the lies she told afterward. Stand up for yourself, and your attorney will handle the rest. They have treated you abysmally.

Don't give up nursing for this. You sound like an incredible nurse, and the profession needs more like you, not less. The good thing about nursing is that there are so many fields to go into when you are tired of working in one. I hated the whole med-surg thing, but I found my calling when I applied to a long-term care facility (nursing home.) The pace is normally much slower and the personal care you can give is so rewarding. There is also psych nursing, school nursing, insurance, travelling, surgery... heck, you can even nuruse on a cruise ship! Don't let this hellhole destroy your dreams.

Under no circumstances should Tony let admin. know about his posts here. That could buy him a world of hurt.

I wish you the best, Tony. You sound like a skilled, compassionate nurse who is a strong patient advocate...the kind of nurse we all would want caring for us/our family members.

Specializes in Medical.

I have no words. Except to say that it sounds like you did an outstanding job in an impossible situation. I ought to be surprised that, rather than being threatened and chastised, management aren't rewarding your expertise and skills. Of course, I'm not surprised. We all know how bad management responds to situations like this - all CYA and shifting system problems to individual staffing responsibilities. Surprising they can't adequately staff the place :uhoh3:

You, though? Awesome!

I am a new grad and your story is horrifying to me. It sounds like you did better than the best that you could and instead of placing that patient in danger, it seems to me that you saved his life.

Specializes in Case Management.

I am speechless. I wanted to tell you how sorry I am that you went through this, Tony. It is horrifying. This is why we have a nursing shortage. You are in no way to be blamed for this. Best of luck with whatever you decide to do. You don't need a hard job like this, there are better places to practice nursing with nothing like this kind of stress. Take care. :uhoh21:

Specializes in ER.

I think that may be the worst story we've seen on the boards. I too would have been sorely tried in that office, and very likely to have told that manager exactly where she could shove that reprimand.

This would be a great example to bring to the media, but that has to be your decision Tony. In any case, you saved that man's life, no matter what the charge nurse or manager do they can't take that away.

I know you want revenge and I know I said you should go public, tell TV and docs, etc. but I don't think you should do it, not yet.

Wait until you get a signed agreement from this employer that they are not going after your license and are not firing you. HR big doodoos will show them how to be vicious and cutthroat and put stuff in your file that you were stealing narcs or whatever other evil lies they can come up and were fired for that stuff.

There could also be a backlash from the patient's family if they know who you are talking about, HIPPA violations, and so forth. Tread lightly right now, rest, clear your head.

You probably should do the EAP thing but realize that your employer gets a report - not real detailed but they probably talk about people, even if they don't write about you to the employer.

Tread lightly for now. Let a little time go by, wait til you're calm before you act. I wish you all the best. You sound like a nurse who is truly wonderful, a caring, skilled, experienced professional nurse. May God richly bless you, Tony. He will open new doors for you. Now may the peace of God, that passes all understanding, keep your heart and mind through Christ Jesus.

Specializes in home & public health, med-surg, hospice.
Tony, words fail me as I read your posts. You sound like a fantastic nurse thrown into a situation that would surely have resulted in at least one sentinel event had it been a less experienced nurse.

I assure you, not all hospitals are like the one you describe--yet.

Situations such as Tony's described should serve as the grim reality that nurses have indeed lost control of their practice, and the results are disastrous for patient and professional alike.

:yeahthat: :yeahthat:

Walking rounds. There has been some resistance to going back to this at my hospital but I am all for it. I always tell new nurses that I think that one thing that saved my butt many a time when I was a new nurse was to physically eye ball my patients before I started my shift. I started on night shift surgical with large patient assignments and had my share of finding IV dumps (in those days we rarely used pumps), patients on the floor, etc. It is very much worth the time for the reasons you outlined in your post to do a quick walking round, it holds the previous nurse accountable and can avert disaster.

Specializes in Emergency, Cardiac, PAT/SPU, Urgent Care.

I agree with what other posters said - you need to get out of that place if you can and find a new job. Are you a member of your state's ANA? If so, give them a call and see what they suggest. Even if you aren't a member, they might be able to offer some good advice. Good luck to you - I'm so sorry that you had a horrible shift like that.

Your post reminded me why I left my last job 2 1/2 years ago and never wanted to go back. Shifts from hell like that were getting more and more common in the PCCU I worked in and a 6 patient load was standard. We also took titrated drips and as soon as a patient was off the vent, we got him.

If anything like this ever happens to you again, call the agency supervisor on call and tell her your license is on the line as well as the agency reputation. At the very least, she'll start making some calls and get some action. You have one more level of supervisory personnel working in your favor, use them.

In any case, I hope you've written this whole thing up, saved your notes, etc.

Nursing was not like this when I started 20 years ago.

Tony, I know this is easy for me to say but if I was you, I would find a new job now! Are jobs in NYC plentiful? If so, go find one that will treat you as a true professional and not just a warm body.

Your patient, (the fresh heart one), was so lucky and blessed that you were his nurse! It's obvious you are a caring nurse, get out of there before that awful place costs you your license.

I thought I was busy and had bad days until I read your note. OMG! how horrible!

take care,

Wayne

What did the unit secretary do wrong?

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