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.
Sodie, BSN, RN
41 Posts
Wow!! I suppose that you didn't think that shift would ever end. I really shudder the thought that administration is pointing fingers. We have a duty as nurse to advocate for our patients. We also have a duty to report on them acurrately.
First of all, is there a written policy not to give fresh open hearts to agency? Or is it a policy understood between the staff nurses in the unit?
Second of all, doesn't the hospital have an obligation to provide appropriately trained staff to the appropriate patient? In other words any nurse (agency or not) should not be given a patiet that they are not qualified to take care of.
Another thing, I have heard the abandonment threat before... but the charge nurse should have reconsidered the assignment. The charge nurse is at fault for failing to listen to your concerns. Unfortunately, it is the charge nurses word against yours, but I would keep record, for future reference in case this issue arises again. If you have an issue such as this, I would contact the nursing superviser and have it documented that you expressed concern about the assignment, however the charge nurse declined to change it.
In view of the fact that you had a patient that coded only a few minutes into your shift, I do not see how it was possible for you to actually assess the other person any sooner. It is policy of our institution that a code team responds to the codes.. When the team arrives, the nurse who has the patient remains in the room and maybe one other staff (possibly charge nurse) however, the rest of the staff has the responsibility to check on your other patients while you are caring for the coding patient. This way, others are not neglected. I know that everyone is busy, but if you go to a courtroom, no one wnats to hear that it wasn't my patient. A nursing staff should be a team. Somehow or another the rest of the staff on the unit shuld assist the nurse with the unstable patients (this includes that charge nurse).
As for the sorry report--- This has happend to me before. I got a bad report on a patient on a PCCU. Her heartrate went up to 150 during the night, they suctioned her without an order because they didn't want to call the MD in the middle of the night. I was told "She is fine now and resting comfortabley"Well, hello... If you have never had to suction a patient in the past 3 nights that they have been there and the HR goes to 150, wouldn't you think something is going on? When I entered the room, the patient was blue, foaming at the mouth with a sat of 68%. I called RT and gave the patient oxygen, we suctioned her, called the MD, stablized, etc.. 2 hours later her ICU bed was ready. My co-workesr checked on my other patients and gave my meds. Thank God for them helping me catch up because after I got back to the unit, another patient started having chest pain, she coded, then died. If it hadn't been for my co-workers checking on my patients, they wouldn't have seen a nurse until 4 hours into my shift.
I really hate it for you that you got into this situation. It always seems that the nurses that are really trying to take care of their patients get into messes like this. It is so difficult when you do your best to have someone else not care about what they are doing. It sounds like you really did what you could to care for your patients. I would do as the others have suggested. Write it down. If you continue working in this institution, you may have issues like this again.
One more question-- We have a process that we do in instances where "incidents" like your scenario are investigated. You probably have heard of it-- Root cause analysis (RCA). Maybe they only do a RCA in sentinal events leading to death, but we have done them in near misses like yours to review the process. Why did this situation occur? What were the forces? Was it the process that the institution used that contributed to the occurance or the outcome? Why was this patient moved out of CVICU when he was? Was he actually stable when he left CVICU? ETC....
It can be a good information session. Generally, someone from administration, the manager of the unit, the persons involved and any other staff members that can help review the occurance attend. It is not to point fingers, but to look at the occurance from many angles and perspectives... an information gathering session, so to speak to identify contributing causes. It sounds like this approach to your situation would be helpful in identifying several key things that took place in this scenario that can be changed to prevent it from happening again in the future.
By the way, why was the secretary written up? What was her involvement? Also, what was the PCA written up for? Finally, why wasn't the charge nurse included in the write up?