Paitent Coded; All Went Poorly

Published

Specializes in Case mgmt., rehab, (CRRN), LTC & psych.

Today I responded to the most pitiful code ever. Keep in mind that I work at a LTCF. Here's a list of what went wrong during the code.....

1. The crash cart was not stocked, yet the night nurses have been initialing that it has been fully stocked for the past two weeks. I attempted to hook up the suction machine before discovering that there was no tubing or yankauers in the drawer.

2. 'Code Blue' was not announced over the external paging system. I wouldn't have known about it if I didn't spot a couple of people running to a particular patient's room.

3. A bunch of people were standing around in the patient's room with their hands in their pockets, doing absolutely nothing. At least they could have offered to take over the task of the chest compressions, since our hands and arms tend to become exhausted.

4. The patient coded during the lunch hour when the majority of the nurse managers and other employees had left the building to dine at restaurants.

Any questions, comments, or opinions on this matter? Do you think I'm being overly critical? By the way, the code was unsuccessful (of course).

Up Vote Up Vote ×

did anyone call 911?

an incident report needs to be filled out.

if 11-7 is stating the code cart is stocked and that isn't the case, then someone needs to be accountable.

also sounds like the staff developer needs to do a mandatory inservice immediately. no chest compressions???? scary.

leslie

Up Vote Up Vote ×
Specializes in Education, Acute, Med/Surg, Tele, etc.

Oh my! That always happened to me at the ALF I worked in...if it was lunch when employees were busy downstairs with residents, and management was out for thier always 'extended" lunch breaks...there was a code upstairs! UHG!

I know I have posted this before but it is so funny!

My first in hospital code was the biggest three ringed circus I had ever seen! The pt had gone into a v-tac and started to go asystole. Between this very short period of opportunity the nurses got the defib pads on the patient (pads mind you not paddles, they did away with the paddles), and were about to shock....

A doc suddenly rushed in along with about 6 residents eager to perform a code! The doc screamed at the nurses for not doing compressions and jumped onto the patient...too bad "clear" had been called a milisecond before hand, and a nurse had to tackle the doc off the pt.

Meanwhile I was there assisting with a bad IV line and trying to restart when they said 'clear' and I backed up hands up to signal I was safe. Lo and behold there appeared a intern (as I was gasping at the doc on the pts chest!) with a doppler probe on the pts foot!?!?!?!? WHAT!?!?!? The man is in asystole you dolt, not going to find a pedal pulse, and hey...ever hear about metal objects and defibs going off! I wound up tackling him!

SO two nurses face down on the floor with suprised intern still holding the probe, and a doc unconscious on the floor (get got zapped). He was easy...and another doc gave him a small shock and back to normal..but needless to say very angry! LOL...was his own fault!!!!!!

IN all of this...there was hardly room for anyone or anything with the overly excited but hands in the pockets interns! So when I had to tackle the intern...three others fell over like dominos! LOL!!!!!! All my victims were okay! LOL!

The patient sadly died...seconds were crutial before or just after asystole and with all the circus in town...it was delayed too long.

Then my nurse manager yelled at me once all was done saying "that wasn't your patient..why were you in there"...I told her that a code situation...you go to see if you can assist...I was next door! Then the intern came up and hugged me right in front of her...hearing what she said...he said "you are a life saver...way to go nurse...I will have my eye on you for future employement with me!".

I had a huge grin and the manager let up! LOL!!!!!!

This should be made into a comedy skit!!!!!!

Up Vote Up Vote ×
Specializes in Med-Surg, , Home health, Education.

Sounds like it should be a performance improvement project. Maybe bring up the issues with the DON or administrator and see how you can prevent this from ever happening again. What if it had been a staff member? I was at a Code that was similar that was in the report room with a nurse! No suction or O2 hook ups. It's amazing that this nurse survived! Some of the CNA's at our LTC facility have never gone through BLS.

Up Vote Up Vote ×
Specializes in Case mgmt., rehab, (CRRN), LTC & psych.
did anyone call 911?

an incident report needs to be filled out.

if 11-7 is stating the code cart is stocked and that isn't the case, then someone needs to be accountable.

also sounds like the staff developer needs to do a mandatory inservice immediately. no chest compressions???? scary.

leslie

One nurse did call 911 about five minutes into the code (which was too long). Chest compressions were performed, too. However, the people who stood around in the background could have offered to relieve the person that was doing the chest compressions since the hands and arms tend to become fatigued. This code was, in my humble opinion, a fiasco...
Up Vote Up Vote ×

I was thinking of temping on the night shift in some nursing homes, but this is the kind of thing that would scare me away. i worked in two nursing homes recently, and neither did mock codes, but they should. when i was a clinical assistant in the e.r. my job was to get the ice for the arterial blood gasses, and do compressions. it is important for everyone to have a designated role ahead of time, because you sure don't want to improvise in a panic.

Up Vote Up Vote ×
Specializes in Case mgmt., rehab, (CRRN), LTC & psych.
Some of the CNA's at our LTC facility have never gone through BLS.
I work at a large 205-bed LTCF and none of our CNAs are BLS-trained or certified. All of the aides should know CPR since they're often the first people to spot unconscious patients and, therefore, can respond within that first critical minute.
Up Vote Up Vote ×
Specializes in Education, Acute, Med/Surg, Tele, etc.

One of the reasons I left my ALF is because they started hiring non-certified caregivers, and they didn't even need a cpr class..and they were to pass meds! EKKKKKKKKK! And they didn't require CNA's to know CPR either, since they didn't want to shell out the money for classes! They need to know this for when seconds count!!!!!!

I fought hard and long to even have a automated defib in the facility but they wouldn't do it saying that our residents were all DNR. Ummmmmmm hello, not all of them where, pts families may not be either, and all the staff were full code!!!!!!!! Isn't that worth it, or are the employees expendable to the point of death???? I still lost my case...and got written up for insubordination with my boldness (boldness meaning I didn't listen to their poliet way of saying shut up and don't think!).

Up Vote Up Vote ×

When I worked at the hospital, the ICU nurses were to be in charge of all codes on the floors until a doc got there.

One time I insisted they do one literally on the floor - when I got there, the patient was lying half in, half out of the BR - poop all over, and he was a large man!! They were all running around trying to figure out how to get him back in bed - he'd have been stiff by the time they found something to lift him with:uhoh3:

A GP who happened to be in house was the first doc there - and he intubated that guy on the floor - I was SO impressed with him!!:) :)

Patient didn't make it.:o

Up Vote Up Vote ×

Oh my...

I was the only nurse on the floor when a lady coded. She turned an ashy grey color,and was gasping. No one knew what to do. I had to pull her (in her wc), hold her feet up, and scream for someone to help me get her on her bed.

Then had to tell someone to go get the cart, which no one knew where it was, nor did it have anything on it we needed....

Thankfully, with CPR, another nurse from another unit, and I kept this lady going until help arrived, but it was enough to put a "hitch in our git-along" as one might say.

LTCF need to be evaluated for crash carts and important things...not just calling in state because of hair in the curlers in the beauty shop, for pete's sake! (Yes, we were cited for that last time. The ONLY thing we were cited for!)

Up Vote Up Vote ×

I fought hard and long to even have a automated defib in the facility but they wouldn't do it saying that our residents were all DNR. Ummmmmmm hello, not all of them where, pts families may not be either, and all the staff were full code!!!!!!!! Isn't that worth it, or are the employees expendable to the point of death???? I still lost my case...and got written up for insubordination with my boldness (boldness meaning I didn't listen to their poliet way of saying shut up and don't think!).

Triage - the reason my LTCF hired me was because of my RN status and years of experience in critical care - yet at every turn, they ignore what I try to tell them. I know perfectly what you're saying about the 'shut up, don't think' reaction from management.:trout:

Up Vote Up Vote ×

Crash cart initialed as stocked but not really stocked.........ohhhh, not good.......

Up Vote Up Vote ×
+ Join the Discussion