Neuro Floor Nightmare!

[WindyhillBSN]

background: i worked on a neuro floor that should have a 4:1 pt to nurse ratio, because it is considered a critical care floor. our shifts are 0600-18:30. i received my 6th patient at about 15:30. problem: for some reason we didn't have a decent pct/secretary. a variety of people were putting in orders. some orders got missed including mine. this was a serious problem since my pt. was admitted with a k+ level of 7.2! the doctor came in an hour later and the orders still weren't put in. he was ****** and looked at me like it was my fault. i dont know how to put in orders and wasn't trained to do so. besides that, the orders were missing. when i finally found them they were tucked behind the front desk computer. by the time they were put in and results were received, night shift was there and got the results. the pt. k+ level was 8.0. the pt. could have coded. so obviously the night shift nurse looked at me like it was my fault, and potrayed it to the physician that way. i'm so upset and depressed i don't know what to do. in the midst of all this i had other patients and physicians pulling me in different directions. i never want to go back. what should i do??

[muesli]

Incident report, talk to your manager, fill out an unsafe staffing report if one is available, don't know if you are union or not. Next time you can not safely take an assignment, refuse it.

Some ways to learn from it: learn how to put in orders and do everything the secretaries do. Demand from your manager that you spend a few hours or a day shadowing a secretary so this doesn't happen again. If you knew the patient was admitted with a high K level (or any other abnormal lab), and you don't see orders addressing this, you need to be proactive and page the physician. Better to withstand the embarrassment of them telling you they already put in an order than missing a key order that could save a patient's life.

[SnowboardLovinRN]

At my facility "noting" the orders means that you have checked that they are entered. Even if they are checked off and faxed by the secretary we have to sign to say we have reviewed them. Remember that secretary does not have the training to be responsible for prioritizing entries. Maybe in the future peak at your orders before the secretary starts. That way you will know what to expect from the plan of care, who is on the case, what diet the pt is on, and what meds are due (and if they have any PRNs you may need).

Make it a routine to ALWAYS check your labs! Most (if not all) new admits will have labs drawn, so check on them. Also for a direct admit they must be coming from somewhere? I'm confused why the sending facility would not call to give a report on why the pt was coming to you.

Like other posters said learn from this, and work with what you have. You are ultimately the one that is responsible, none of the other ancillary staff has a license to uphold like your RN. If you dont feel safe accepting another patient, DONT! And if you are in a state with ratios (I am in CA so it seems insane to me).. REFUSE! Remeber to CYA!

[romez]

I don't know how long you have been a nurse, but do not allow this or any other situation that may occur prompt you into doing anything you might regret later. Use this incident as a learning tool. As a nurse you will find that our jobs require 25hrs a day, 8 days a week mental toughness. Some how no matter what the circumstance it's our fault. As you move forward in your nursing career you will find coping mechanisms, use them!!!

Keep a detail diary at home, because healthcare likes to sucker punch nurses, This detail diary will give you the pleasure of the final knockout punch and let me tell you it feels good.

[BOOYARN]

why didnt the doctor order kayexalate when he found out it was 7.2 .....by the time you got to drawing the lab it would have gone down instead of up....well in a perfect world

[DC Collins, ASN]

This is not an, "its your fault" response - I want to clarify that because I know how things can sound over the net. :)

In addition to the good answers above, I would find a way to become the problem solver. It is considered *technically* your fault, in that you are the legally the last line of defense for your patient. My suggestion is that, no matter how busy it is, find a way to adjust your routine to check on any labs within a limited amount of time to verify the orders have been placed. If not, try again. If it continues to be a problem, I would also suggest making a copy of the orders and time-stamp them where those who put the orders in can see you do it. CYA!

And yes, definitely, speak with your manager. It's your license on the line if a pt like that codes.

Good luck, best wishes, and healthy pregnancy!

DC, ED NOC RN ADN

Abbreviations R Us :)

[OldNurseEducator]

When did you know it was 7.2? That should have been your priority. What were the symptoms? How often diud you check the orders? Lots of questions....

[Orange Tree]

As soon as a patient gets to the floor, I grab their orders and info before it gets passed to the unit clerk. If there's something in there that can't wait, I ask her to work on it right away and I make sure to follow up. I can't imagine having the time to enter my own orders....I agree that this was a system failure

The night nurse who looked at you like it was your fault has had days just like the one you had. Don't doubt that! And your patient could have coded, but they didn't.

[OldNurseEducator]

That's exactly what I think, too, Orangetree. Good post! We've all had days like this and that goes with being a busy nurse! The night nurse was just spouting off because she thought she might have done differently. Next time your new patient comes in with a seriously skewed lab value, work on that right away. Thank goodness the patient didn't code. Remember, the patient DID NOT CODE! Keep up the good work. the fact that you are concerned about this makes you an already excellent, caring nurse!

[enchantmentdis, BSN, RN]

Ah, boy am i so glad i left acute care after suffering for 16 years in med-surg/tele/neuro. What the heck took me so long!!!!

[klone, MSN, RN]

Even if you do not know how to enter orders, as the pt's nurse, it's still your responsibility to make sure they get entered, somehow, by someone. IMO, "I don't know how to enter orders" is not an excuse. If I had been that pt's physician, I'd have been pretty POed.

[Katie5]

I am irked when the first suggestion I see to a question is "QUIT".Why should we quit first before finding out if a situation is salvageable?

If you never ask,the answer is always no. OP, speak to your nurse manager and with your pregnant state, you might even have a leverage.

And next time,next shift nurse gives you feaces when it is not your fault,try standing up for yourself.Be assertive and correct her in non-aggresive tones.

[Up2nogood RN, RN]

I'm confused. Did you not know the pts K+ level and thus didnt know about the order or you knew the critical value but couldn't find the chart? If you knew the lab value than you could have paged the MD?

We do not have a unit secretary on days or nights. They got rid of them after we went to CPOE. We still have a few docs that won't enter them but management is working on that and our CN does not take pts so she will enter those. Also we still may get the rare phone order at night and the floor nurse is responsible to take orders and enter.

Regardless all new nurses are trained in my hospital to enter orders. Do we do it often? No, but it's an excellent skill to have. Case in point.

Maybe you can use this as an example, go to your unit safety committee or whatever committee and get them involved in helping to find a solution to prevent a possible sentinel event!

Honestly I've had (and I think we all have) had many shifts like these. Prioritizing is essential, critical labs take precedence over most things and it's not a good situation but the other pts will have to wait for some things.