I work 7P-7A on a fairly busy adult medicine floor. Thursday morning, I reported off to a nurse with whom I've worked for more than three years (and who is more experienced than I am). I knew one of the patients would be discharged. I was correct, and when I returned Thursday evening, there was a new patient in his place. He'd arrived at 1700 or so as a direct admit, diagnoses dehydration and diabetic foot ulcers. She said he was a miserable old man and was only happy after she gave him a supper tray. Also, the hospitalist on call hadn't been up to assess him yet, but did provide a few orders concerning insulin, antibiotics, and diagnostic studies.
I went in to assess the man, and he was cool with me, but not rude or anything. I learned that he took pain medicine at home and hadn't had any all day. I paged the hospitalist and received an order for pain medicine, as well as assurance that he would be up to see the man in person. After the patient's pain medicine kicked in, he was very pleasant and cooperative, deciding to nap until the doctor arrived.
By this time, it was HS accucheck hour. The PCT came out to tell me that the machine was reading "critical high." I told him to repeat the test as per policy and looked on the computer to see what he was before supper. That's when I discovered my problem. No one had yet performed any sort of glucose test on him. But, as I told you, he ate a meal. Also, the RN before me gave him orange juice with his food. The tech came out and told me the reading was still "critical high" (that means greater than 500) and that the patient had said to him, "it doesn't surprise me because I'm really thirsty and peeing a lot. I knew it would be high. And I haven't had insulin in a few days because of insurance issues." The thing is, the admitting nurse, whom I'd relieved, KNEW all of this. Yet did not think it pertinent to do a fingerstick!
Thankfully, the hospitalist then arrived, I told him what the deal was, and he ordered a stat Basic Metabolic Panel. He assessed the patient, wrote a few new orders, then told me to page when the result came back and we'd figure out a plan then for getting his sugar down.
The man's sugar was...*drumroll* 967! His vitals were stable, sodium was low and potassium was high, but he didn't have a gap, so thankfully no DKA. The on-call hospitalist was by this time someone else, and she gave me orders for a NOW dose of 20 units of Novolog, plus 45 units of Lantus, and normal saline at 250 mL/hr, as well as Q2 accuchecks. By 6 AM, his sugar was 170 and his I's & O's began to regulate. So all turned out well, and I was glad that it happened by the time 7AM rolled around (although I was reporting off to a different nurse this time).
What grinds my gears is that NO ONE DID AN ACCUCHECK! I'm sorry, but if a patient is admitted for diabetic reasons, or is a diabetic admitted for any other reason, wouldn't a glucose reading be obtained relatively quickly? (Especially if the patient was a direct admit and therefore didn't receive the usual ER lab studies). I feel terrible that I hadn't asked what his sugar was before supper, but I assumed that this nurse, who is actually one of the most experienced day shift nurses, and whom I've worked beside and known for so long, wouldn't have fed him without checking the sugar. If she had done this, his sugar wouldn't have climbed so very high!
ARGH!
So...what do I do now? Talk to my coworker? Go to management? Write an incident report? All of these things?
This isn't what I would call "normal" for her, but her performance has declined. Every time I follow her, I catch errors when doing chart checks (it's always something different, too...sometimes consults aren't called in but the order for it has been signed off, or lab orders are entered incorrectly or not at all but she has signed them off) and if she's back the next day, I'll tell her about it. Her reply is always something like "whoops...sorry!" But it's never a major error or a huge deal because I fix those problems. Also, she doesn't fill out her flow sheets completely or write progression of care notes even if one hasn't been written in days. So, yeah, I think she's getting a bit on the lazy side. Normally I would say nothing (because she wasn't back yesterday morning), but my charge nurse who caught wind of it wasn't very happy, especially since the patient stated that his sugar was high, he hadn't taken his insulin in days, he was polydipsiac, polyuric, and was admitted for complications related to diabetes. She trusts my judgement and didn't want to tell me what to do, but she usually shrugs things off herself. I take stuff in stride as well if it can be fixed, but something about this feels different in the pit of my stomach...
I think you know exactly what needs to done in this situation. People have reported me over much less than this. Are you a younger nurse? I am wondering why you would let this situation go esp after admitting to us that her performance is declining. We let emotions get involved too much of the time and do not think about how we would feel if we were the ones in the hospital bed at the mercy of someone care. I remember a nurse I was working with a year ago, reported me for 'almost' giving insulin to the wrong patient. I caught it before I gave it, but she reported me. I was upset with her but I got over it. A mature person has to. That report made me more careful when doing insulins. You will simply have to do the uncomfortable thing and talk to her, her manager or someone else in charge.
I love this site! I have so much to learn. I'm surprised that as a diabetic, the pt didn't have a bs check done before eating but if the admit came around supper time, then I could see it getting oopsed. Sad that insurance was such an issue that the pt didn't have insulin at home.
I too have a hard time confronting coworkers on things. I try to go in, do my best, and go home. You sure were on top of everything from pain to the critical glucose. I hope I can pick up on things that seem common sense to more experienced nurses before I retire!
I once had a similar situation, only involving hypoglycemia. The experienced night nurse told me the pt, who was NPO for a procedure, had required D50 for hypoglycemia at 0300. I was late getting out of report and at 0800, when I did his morning Accucheck, his BG was 30. Yes, 30. Pt stated he thought it was little low, but had no obvious signs. Anyway, I had to give him D50 (twice). MD was notified, of course, but did not order glucose in his IVF (he was on NS) and this didn't occur to me either (it was my first day off orientation on this stepdown unit). As a result, the pt got D50 twice more on my shift... however, I made sure that right before shift change I rechecked his BG it before reporting off to the night nurse! Which is what I think the night nurse should have done.
However, I did not confront her about it; in fact, she knew about it because she helped me assemble the D50 syringe (I hadn't had to use it before). Just a week earlier she had left me and my preceptor a pt in respiratory distress which, according to my preceptor, was unusual for this "good nurse". I agree with her assessment of this nurse, and am sure that she will be more careful in the future. Therefore, I didn't mention the hypoglycemia incident again to the night nurse and certainly not to the manager. However, if this were to happen again, I might have to reconsider this.
So in your case, OP, I wouldn't confront the previous nurse, I would just mention (nonconfrontational) what happened with the pt that night; she'll realize she messed up. We're all human after all
this just proofs that hypoglycemia is more dangerous than hyperglycemia,low blood pressure is more critical than high blood pressure,hypokalemia is more critical than hyperkalemia,dont get me wrong both have to be adressed right away but I just personally think that there is a longer time window in treating everything that is HYPER
Good question, but not that I know of. She started on the floor about nine months before I did and was dealing with the aftershocks of a messy divorce at that time, and it didn't effect her work (if anything work was a sweet release). She just seems really laid back lately (as in - over the last ten months or so). I just worry about this for other reasons, too, because she's often charge or a preceptor.
This isn't what I would call "normal" for her, but her performance has declined. Every time I follow her, I catch errors when doing chart checks (it's always something different, too...sometimes consults aren't called in but the order for it has been signed off, or lab orders are entered incorrectly or not at all but she has signed them off) and if she's back the next day, I'll tell her about it. Her reply is always something like "whoops...sorry!" But it's never a major error or a huge deal because I fix those problems. Also, she doesn't fill out her flow sheets completely or write progression of care notes even if one hasn't been written in days. So, yeah, I think she's getting a bit on the lazy side. Normally I would say nothing (because she wasn't back yesterday morning), but my charge nurse who caught wind of it wasn't very happy, especially since the patient stated that his sugar was high, he hadn't taken his insulin in days, he was polydipsiac, polyuric, and was admitted for complications related to diabetes. She trusts my judgement and didn't want to tell me what to do, but she usually shrugs things off herself. I take stuff in stride as well if it can be fixed, but something about this feels different in the pit of my stomach...
I think you are very smart and perceptive to pick up on something not being right with your colleague. It could be aftermath from the divorce (speaking from personal experience, one does not get over a divorce easily---and I was a mess when my ex remarried, not because I wanted him back or anything but because he was not very sensitive in telling the kids or me---and it hurt all of us.) It could be some other issue going on with your colleague as well.
Previous posters have given you excellent advice. You need to speak to your colleague in a gentle, non-threatening manner, maybe ask if she's okay and then point out that you've noticed things---like this blood sugar incident---that make you wonder if she's perhaps distracted at work or has something going on in her life. As DirtyBlackSocks suggested, speak to her in the way you would want to be approached---with kindness and compassion rather than accusations. If this pattern in her behavior continues, someone WILL speak to her and that person may not be very kind. (BTW, your colleague could risk discipline in the form of a verbal or written warning, suspension, or termination if this pattern of behavior continues, so you are doing the kind thing by bringing it up to her.)
The other consequence of her behavior is that she could harm or even kill a patient. Yes, mistakes happen in health care, but we need to minimize those mistakes as best we can. If a nurse is habitually distracted to the point at which she is not performing appropriate assessments, she could be a danger to her patients.
Document, document, document everything that concerns you and if she shrugs off your comments, you may need to take this to the attention of your charge or manager. You would not be a snitch; you are only a snitch if you consistently run to the manager rather than try to approach the colleague about whom you have concerns.
You seem like an excellent, sensitive nurse. I am sorry you are in this difficult situation but I am confident you will do the right thing and do it with empathy and caring toward your colleague.
Specializes in Infusion, Med/Surg/Tele, Outpatient.
I agree with many of the other posters. You should talk to your peer, if only to say "hey hows life going? - insert chitchat here- I've noticed you seem a little off/preoccupied/different lately. Anything I can help with?"
Also, you are right to be concerned. Now that we have the 8 rights of med administration... if she gave the ordered 10 units of novolog with his meal, how did she do the right assessment and documentation without an accucheck?
I don't understand what you're asking. We have set sliding correction scales, yes, but physicians are not required to choose one of those. We also have a hypoglycemia algorithm, but not one for critical blood sugars (anything greater than 400 is considered critical).
Sorry. I had just gotten home from work, and when I'm tired, I tent to keep my posts brief. What I was wondering was, were there not any orders in place for the previous nurse? It sounds like there were. Even in the absence of orders, it would have been common sense to have done an accucheck on this patient.
Of course, like the others, I would agree that you should mention this to her in a "hey, by the way, remember that one guy?" sort of way. Non accusatory, nonjudgmental, gentle.
However, I will disagree that this would not be inappropriate for an IR. This is a completely appropriate situation for IR documentation. The purpose of IRs is not to be punitive when people screw up, but for process improvement. In this instance, when the IR is investigated, the investigation will include a breakdown of the sequence of events, and ways that processes can be improved to prevent similar events in the future.
But, as others have mentioned, some hospitals do use IRs in a punitive way (mine does not; my facility uses them for process improvement; the disciplinary process is a separate process) so that when you write an IR, it is viewed as "writing up" another nurse. I don't know if this is the case in your facility.
See my thread in the Emergency Nursing forum for a similar dilemma.
I'm sorry, but if a patient is admitted for diabetic reasons, or is a diabetic admitted for any other reason, wouldn't a glucose reading be obtained relatively quickly? (Especially if the patient was a direct admit and therefore didn't receive the usual ER lab studies). I feel terrible that I hadn't asked what his sugar was before supper, but I assumed that this nurse, who is actually one of the most experienced day shift nurses, and whom I've worked beside and known for so long, wouldn't have fed him without checking the sugar. If she had done this, his sugar wouldn't have climbed so very high!
#1: A patient being admitted with dehydration and diabetic foot ulcers was going to have high blood sugars, this was a foregone conclusion. Add in the fact that he had not taken his insulin for several days and the fact that she fed him supper is not the reason his blood sugar climbed very high. What was his A1C? I bet its sky high. Your co-worker not checking the BG is a problem but in this case, it is not THE problem.
The docs know this and he should have been admitted (at a minimum) with orders for q4 accuchecks with insulin coverage, IV fluids and now labs(they didn't need to be stat).
#2: I worked 3-11 for many years as well as 7p-7a, 11-7, etc. Actually I've worked every shift combination possible. 3P-7P are the busiest 4 hours of the day even without an admission complicating things. While it is not acceptable that your co-worker did not do the accucheck, it is not that hard to understand how it happened either especially on a diabetic floor when you are trying to get all those blood sugars done and covered before dinner in addition to the other routine and not routine stuff.
#3: It sounds like you have spent a lot of time checking up on all the things your co-worker does not get done. That is quite typical of night shift nurses IMO, they were usually the most judgmental during report and they were always the first ones to point out what didn't get done. God forbid they should have to do something that was left over from the previous shift! I'm sure most of your concerns are valid. Everyone has suggested you approach her in a nonjudgmental way. If her performance is as bad as you mention and she is as lazy as you say, then you are not the only one to notice so stay out of it. The charge nurse is aware that she didn't check the BG and at this point, the ball is really in his or her court to address the situation. If you run into a situation where she made an error that was truly serious, then report it.
Thanks, but, as I stated, I hate confrontation and am terrified to even mention this calmly to someone. I am angry, because I was left to deal with this issue. I don't think I am wrong in my anger. I'm pretty sure other people here would admit to being ****** about the situation at hand. However, in my anger I have no plans to sin (which wound be tantamount to "blowing a gasket.") So, even if I do end up needing to go to management (and I would choose the assistant manager who has known both of us for a long time and used to be a staff nurse alongside of us) or to write an incident report (dear heavens NO, I think that's even worse) I wouldn't be accusatory or emotional. I was just wondering what, to improve patient outcomes and prevent errors of this nature, I should do. Thank you all for your suggestions.
When you received report on this patient, did you ask about blood sugar? I know it's difficult to anticipate every question you might like answered when you're taking report on multiple patients, but for someone coming in with complications related to diabetes this would be a pertinent question. At which point your co-worker would probably have slapped her forehead, looked aghast, said "I'm such a nerd", and flown out of the room to get a finger stick :)
As things are now, it sounds like a communication breakdown during handoff involving multiple people who were all very busy and distracted. Such is healthcare. I know you feel angry and don't like confrontation--but if you can redirect your frustration at the "system failure" (which can involve multiple people, some more to blame than others, but who cares?) you may find a "blame-free" way to approach your colleague.
Specializes in Medsurg/ICU, Mental Health, Home Health.
#3: It sounds like you have spent a lot of time checking up on all the things your co-worker does not get done. That is quite typical of night shift nurses IMO, they were usually the most judgmental during report and they were always the first ones to point out what didn't get done. God forbid they should have to do something that was left over from the previous shift!
Yes, you've caught me. I really just want my friend to get fired. Instead of caring for patients, I go around and read her charts to see what has and has not been done. Then I add it to my list in her entry of my notebook of atrocities committed by day shift nurses. All of the night shift nurses have these notebooks. On Monday, Wednesday and Saturday nights, we share the entries with each other. It's such a blast! The best is biting the heads off of new day shift nurses during report, reprimanding them for not clearing their IV pumps. That's why I became a nurse!
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katherine100, LPN
310 Posts
I think you know exactly what needs to done in this situation. People have reported me over much less than this. Are you a younger nurse? I am wondering why you would let this situation go esp after admitting to us that her performance is declining. We let emotions get involved too much of the time and do not think about how we would feel if we were the ones in the hospital bed at the mercy of someone care. I remember a nurse I was working with a year ago, reported me for 'almost' giving insulin to the wrong patient. I caught it before I gave it, but she reported me. I was upset with her but I got over it. A mature person has to. That report made me more careful when doing insulins. You will simply have to do the uncomfortable thing and talk to her, her manager or someone else in charge.