Night Shift Nightmare

defeatedcreek · Nov 25, 2007

Don't feel bad, Stephen. I have my own event to share. But first off, I want to point out that you are using one pronoun here, "I". If you were working with anything resembling a team, shame on them.

Recently one of my patients was a retired army veteran. He was admitted r/o ACS because he had chest pain at work and took his spray and passed out. Nothing uncommon.

We ran the patients cardiac enzymes and coags to the lab. Patient admissions fooled around and we couldn't get his labs ordered in our system (yay technology). When they were taken to lab we waited and after an hour a flippant lab tech says "oops, hemolyzed." Coag panels take more time but not quite that long. The samples probably sat up there needlessly until someone took the time to spin them. The labs were re-drawn to the patients chagrin.

Meanwhile no critical values were reported from the lab. The patient's VS appeared normal. No major complaints. Telemetry running swell.

At 0500 the feces hit the fan. Troponin levels were off the scale. We ran a continuous EKG. You got it - the guy had an MI right under our noses and was immediately taken to intensive care.

I look back and see a trail of incompetence from the lab and patient admission. But I cast so much blame on myself as well. I strongly suspect that despite the preponderance of "I" in your post that your stroke was probably the blame of a team rather than just yourself.

Neither of our events will be our last. It's not our necessarily our incompetence that leads to the events but our zeal for our profession makes us insanely angry at ourselves. Look back at the event: think of ways to assess in situations like that, ask other nurses for advice, etc. I brought down the axe for our ward and, along with lab, we are going to start working on communication and handoffs to avoid further incidents like ours. I'm also doing an inservice on avoiding hemolysis in our samples and knowing when to call the lab when results are late.

In other words all you can do is reflect, conclude, and educate. Avoid pointless introspection.

Don't lose hope, buddy.

defeatedcreek · Nov 25, 2007

I was also talking to my vastly more experienced charge just now and she says bed strokes are always the worst to assess. In fact unless the patient gets up to void, it is not uncommon to miss their occurrence.

She had a similar circumstance sometime during the annals of her career. She feels your pain.

SuesquatchRN, BSN, RN · Nov 25, 2007

I strongly suspect that despite the preponderance of "I" in your post that your stroke was probably the blame of a team rather than just yourself.

Old people get sick and die even without surgery. Throw in the trauma from a knee replacement and it can happen.

Should you (OP) have caught it? How? Telepathically?

Ease off of yourself.

Stepher Gale · Nov 26, 2007

Thanks everyone. I feel a lot better now that I know how I am going to learn from this experience. After all, good judgment comes from bad. I just feel really bad because I did not even suspect it. I thought the signs she was exhibiting (particularly the drowsiness/sedation) was associated with the Ambien. I wasn't even looking. However, unfortunately after a week of kicking myself, I now know how I will change my ways to prevent this from occurring again. I know the stroke was NOT my fault. However, I feel at blame for not picking up on her symptoms. Even though she was not a candidate for TPA from her surgery, I still feel somewhat responsible. Around 0230 that morning, my aide even told me while we were in the room messing with her foley, etc she thought something was wrong. I explained to her about the Ambien, etc. RED FLAG! Anyways, thank you all for your words!

TazziRN, RN · Nov 26, 2007

Anyone who needs neuro checks through the night should not be given sleep meds. On that note, when you give a sleep med there should be no reason to wake the pt to assess them......that really pisses patients off. I wouldn't beat myself up. You had no reason to suspect a stroke.

Shantas · Nov 26, 2007

I can feel your pain.....we are all human..I also had a terrible experience one day during a day shift. I was covering for a RN who was on her lunch break. She did not tell me much about her patients, all she said they were all doing ok and she left. All of a sudden the son of this pt comes running to the nurses station. He told me something was not quiet right with his mother. I went to the room to check up on the pt, I see an elderly lady laying in bed with a o2 mask on her face and a NG tube, I check her breathing and I thought she was breathing. So I come out and was looking for my charge nurse so that she can go to the room and double check the pt just to make sure the pt is ok. I did not have any clue about this pt. So charge RN goes to the room and calls the code. I was running with the crash cart, I hear the son yelling at me "its your fault, I told you mom was not doing ok"....so on. The pt happened to be DNR, I did not know that. Once the code team opened the chart they found out she was DNR.

In the mean time the son was yelling and yelling, I just stepped out of the room and went in the break room in tears...I felt bad and guilty that I did not call the code while I was in the room. I did hear her breathing, its was slow and laboured, she already had a o2 mask but the son thought I was responsible for everything.

So now before I cover for any nurse I make sure they give me a good report about their pts....not just "they are fine."

CaLLaCoDe, BSN, RN · Nov 26, 2007

I can feel your pain.....we are all human..I also had a terrible experience one day during a day shift. I was covering for a RN who was on her lunch break. She did not tell me much about her patients, all she said they were all doing ok and she left. All of a sudden the son of this pt comes running to the nurses station. He told me something was not quiet right with his mother. I went to the room to check up on the pt, I see an elderly lady laying in bed with a o2 mask on her face and a NG tube, I check her breathing and I thought she was breathing. So I come out and was looking for my charge nurse so that she can go to the room and double check the pt just to make sure the pt is ok. I did not have any clue about this pt. So charge RN goes to the room and calls the code. I was running with the crash cart, I hear the son yelling at me "its your fault, I told you mom was not doing ok"....so on. The pt happened to be DNR, I did not know that. Once the code team opened the chart they found out she was DNR.
In the mean time the son was yelling and yelling, I just stepped out of the room and went in the break room in tears...I felt bad and guilty that I did not call the code while I was in the room. I did hear her breathing, its was slow and laboured, she already had a o2 mask but the son thought I was responsible for everything.
So now before I cover for any nurse I make sure they give me a good report about their pts....not just "they are fine."

Listening to this story makes me want to make rounds immediately on another nurse's patients when she's jetting off to lunch. You'd be amazed how often my patients differ in appearance from what was told me during report.

Stepher Gale · Nov 26, 2007

I can feel your pain.....we are all human..I also had a terrible experience one day during a day shift. I was covering for a RN who was on her lunch break. She did not tell me much about her patients, all she said they were all doing ok and she left. All of a sudden the son of this pt comes running to the nurses station. He told me something was not quiet right with his mother. I went to the room to check up on the pt, I see an elderly lady laying in bed with a o2 mask on her face and a NG tube, I check her breathing and I thought she was breathing. So I come out and was looking for my charge nurse so that she can go to the room and double check the pt just to make sure the pt is ok. I did not have any clue about this pt. So charge RN goes to the room and calls the code. I was running with the crash cart, I hear the son yelling at me "its your fault, I told you mom was not doing ok"....so on. The pt happened to be DNR, I did not know that. Once the code team opened the chart they found out she was DNR.
In the mean time the son was yelling and yelling, I just stepped out of the room and went in the break room in tears...I felt bad and guilty that I did not call the code while I was in the room. I did hear her breathing, its was slow and laboured, she already had a o2 mask but the son thought I was responsible for everything.
So now before I cover for any nurse I make sure they give me a good report about their pts....not just "they are fine."

That is horrible! I would have cried like a big fat baby for days had this happened to me! I am starting to feel a lot better because I realize these kinds of things happen, and my lady stroking without me picking up on it is nothing compared to your situation. Definitely a learning experience! Thanks for sharing!