Sentinel Events- Political and Ethical dillema

  1. i have a question and i just want some honest feedback.
    when a sentinel event occurs as a direct/indirect consequence to a coworker's actions what do you do ?there is hippa to think about.....but then....there is the family......and no one wants to think about them....with risk management dept's influence very very few employers truly disclose what actually cost that family their loved one.
    anyone who has been a nurse any length of time knows someone who knows someone....that witnessed the after effects of a incorrect dose/drug given to a wrong patient.tv has a million blogs telling everyone "how many errors occur in hospitals".was the family informed? i have very strong feelings on this topic....bc .....the patient......well that is / was someone's mother father brother sister child spouse..etc etc. i feel like when hcf's cover these events up ....it is such a betrayl of the trust they placed in that hcf.but...i am open for other points of views .....do you think it might inflict more harm than good by giving full disclosure to the families when a patient suffers as a result of a medical or nursing error?
    in the last few weeks,.. we have seen news reports of adult strength heparin that was erroroneously given to newborns....subsequently some of those children died and the hospital had to admit what had happened to these otherwise healthy new babies.....but what about if they were very ill to begin with....and the hcf passed off a death/sentinel event as just a sad but natural event when in fact it was the result of a medical or a nursing error?i dont think this falls under the beneficence definition. how many of you have worked at health care facilities that try to cover up the events...and how many of you work for facilities that are honest with the families?
    ****sorry for anytypo's!!!
    Last edit by Keysnurse2008 on Sep 23, '06
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    About Keysnurse2008

    Joined: Sep '00; Posts: 581; Likes: 163
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    7 Comments

  3. by   VivaLasViejas
    This is only my opinion, but we live in such a litigious society that many businesses almost routinely refuse to issue formal apologies anymore, because they are sure to be sued! In fact, as a relative of several legal experts, I myself have been advised never to apologize for any error I might commit in the course of my career..........not because of any risk to my license, necessarily, but to protect my family from being bankrupted by a civil action.

    It's a sad commentary on our times when being honest and admitting mistakes can literally cost one his or her livelihood, but one would have to be totally naive NOT to be afraid of the possibility. Hospitals and other health care institutions know this, and thus even when they are grievously wrong, they have to act as if everything is fine. "Deny, deny, deny" is the watchword.
  4. by   Keysnurse2008
    sad....but true. i see families that even when they are receiving the best medical and nursing care they are aggressive and threaten litigation if "x" doesn't occur. those families....most of them are just scared bc of the unexpected event that brought them to us.....but a few....well you know.
    but when you see a standard of care that has been deviated from...and see the cascade of events that follow that negatively impact the patient....it is difficult to not think about that patient's family....their mother....their children...etc etc. it's almost like people loose sight of the fact that it is an actual person that was affected.....and all they want to do is hush everyoneup asap. healthcare without a conscious....kinda makes me a little ashamed to be in the healthcare profession.but...i see your point....if they acknowledge fault they stand in danger of litigation that could impact their ability to help others.i guess that's why some states have "caps" on what families can actually get on malpractice claims. in a society where reimbursement has dwindled....i can see your point.
  5. by   luv4nurses
    This has happened at my facility recently. A patient who was expected to be discharged endined up aspirating because the nurse administered the tube feeding in a flat position. The facility covered it up but I have been so disturbed by this because the family was expecting him to come home and I can't help feeling bad knowing the pain they must feel losing their dad while the nurse who caused this is walking around scott free. This case is open and shut because it is considered negligent homicide because of her "mistake". The family is left in mourning while she is still earning a "living".
  6. by   RNS for Unity
    TNN Nurse, Hi it's RNS for Unity, wondering how you're are doing? You had sent me an E-mail on my computer.
  7. by   Keysnurse2008
    Quote from rns for unity
    tnn nurse, hi it's rns for unity, wondering how you're are doing? you had sent me an e-mail on my computer.
    i am doing ok....i have been a nurse for going on 20 years....and this patient ...bothers me. i still think about the patients 3 young children...i think about the lack of remorse on the nurses behalf.....she is still living her life.....and the patient...isnt. healthcare facilities....especially risk mgmt depts....they dont want to get the reports of sentinel events like this one. they .....arent the ones though.....that have to see the look of devastation when the families realize that their loved one is "gone" and that their lives will not ever be the same. i think about this patients children.....that will never have the luxury of calling their parent when times get tough throughout their lives....this patient will never see those 3 kids graduate high school....never see their wedding...never see their grandchildren.president bush ( whom i dont usually agree with) did do one positive thing.he signed a law ( pt safety act) to begin the step in the right direction that mandates self reporting of sentinel events like this by hospitals. but....what is still lacking is......these hospitals go to such lengths to not acknowledge these kind of things actually occurred. when i informed the unit manager of my healthcare facility...the unit manager allegedly "lost" the incident report...and the nurse who coimmitted the act...well she actually forged numerous documents attempting to discredit my account of events. i then submitted the documents to a handwriting examiner to ( suprise suprise) examine and he said that the documents she submitted that support her acct of what allegedly happened was forged by her....meaning.....she tried to cover her tracks and not only committed an act that resulted in injury to a patient...but then forged documents and signed others names to the forged document.want to know where that nurse is right now? still at work....at her job. this nurse...i used to actually like this nurse before that day....now....any time i hear that nurses name i see that patients mother and three kids in my mind. i can relate to the nurse who wrote about the patient dying of aspiration.....society tries to make "grey" areas when broached about ethical issues.......but in my eyes it is either black or white.....it is either wrong or right......with no grey areas.the laws need to mandate a "site" where any healthcare team memeber can report events like the ones described there.....and not wait on risk managements approval ( which will never come)...to report events like these. these patients are people...with lives thoughts...memories...personalities.....and when events are "covered up" and families are left to believe a lie...it is wrong.so...nationally the patient safety act needs to be strengthened imo.....otherwise we are left to rely on healthcare institutions to get a conscious.
  8. by   imenid37
    Did you see the PBS series "Remaking American Healthcare?' The one segment made me mad about how PGH area hospitals wouldn't band together to fight MRSA because there was a fear of disclosing business secrets. Okay for someone to die, but hey we must assure huge profit margins for these non-pofits. Amazingly twisted? There are mistakes and then there is downright incompetence. Putting a guy flat for a tube feeding is incompetence. That is basic nursing knowledge. Even I remember that from 20 years ago in school. I think it has been about that long since I had a tube fed pt.
  9. by   Keysnurse2008
    Quote from imenid37
    did you see the pbs series "remaking american healthcare?' the one segment made me mad about how pgh area hospitals wouldn't band together to fight mrsa because there was a fear of disclosing business secrets. okay for someone to die, but hey we must assure huge profit margins for these non-pofits. amazingly twisted? there are mistakes and then there is downright incompetence. putting a guy flat for a tube feeding is incompetence. that is basic nursing knowledge. even i remember that from 20 years ago in school. i think it has been about that long since i had a tube fed pt.

    [font="tahoma"]imenid37...you are correct. hospitals do not not want to acknowledge the mistakes that occur bc it opens them up to liability...finicial liability.

    i actually went to an atty over the event that i witnessed attempting to get the hospital to remove this nurse from practice...what happened after that was the biggest mess i have ever seen. medical records were "altered" aka forged by this nurse to cover her a**...she forged nurses documentation...forged the hospital administrators signature etc etc......and the lady is still functioning at her same job. even though the lady lied, inflicted harm to a patient by deviating from the standard of care...even though forensic document examiners have said the nurse forged others documentation.....even though she cant keep her story straight....even though this patient died ....this hospital is soooo concerned over liability to the patients family that they will not even discuss what occurred nor take any action against this nurses liscence. the atty i discussed this with has stated that if the hospital were to take a stand and fire her... that they would be open to liability if the patient family sued in the next 3 years unless the judge ordered me quiet thru a gag order. with her lies so easily p;roved ....and her forgeries in her own writing.........with a dead patient......they dont want to discuss any of it bc .....of money. they have no ethics and it makes me sad to be a member of the healthcare team. i completly understand what you are saying about not acknowledging the mrsa. hospitals dont want to acknowledge that mistakes are made....that infections occur....they'd rather place other patients at future risk by leaving those practitioners in place. i am fed up......i feel that if that hospitals dont care about their patients safety any more than that that the public should be aware of the risks associated with a hospital stay under that practitioner.i am so disheartened about the death of this patient that i am ready to leave nursing. i think about the patients family.....they placed such a huge amt of trust in the hospital.....they trusted them with the one asset that is irreplaceable...a life. the event i am describing.....the event over the tube feeding/aspiration and death....the events you describe of mrsa not being acknowledged and treated....../.all these events all end up in the same room.....the morgue..........a place that could have probably been avoided if the standard of care practices had not been deviated from. it just makes me sad.....to think of a families trust being violated....i will most likely leave the nursing profession in the next 1-2 years unless some major event restores my trust in healthcare. it is all so unethical....hcf's are more worried about their m&m rates than the patients that they are treating. i guess thats why so many hcf's are on hospital integrity agreements and are banned from receiving medicare $$$'s....lack of ethics in healthcare.....just makes me sad.

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