Patient fall

You are human. Humans make mistakes. The important thing is no one was hurt and that you learn from it. Be kind to yourself.

On 5/19/2019 at 10:40 AM, beekee said:

You are human. Humans make mistakes. The important thing is no one was hurt and that you learn from it. Be kind to yourself.

I appreciate it. I try to. It's tough for now since it's still fresh. It's the first and last thing I think about every day. This too shall pass.

6 hours ago, littlemissBSN said:

I appreciate it. I try to. It's tough for now since it's still fresh. It's the first and last thing I think about every day. This too shall pass.

Please contact EAP or talk to someone you trust. This should not be consuming your every thought.

A fall takes two seconds to happen. An alarm doesn't prevent a fall; often it just lets you know to expect to find someone on the floor.

Where their alarms on when you got report at the beginning of your shift? who was the last person to move the patient? I had a similar incident recently and I was not the one that moved the patient to the chair and didn't activate the alarm, a CNA did--so I will not take ownership for the fall. You cant take responsibility for everything, although management says that everything ultimately is the RN's responsibility. If I went along with this train of thought I would be in the psych unit by now.

3 hours ago, Jedrnurse said:

A fall takes two seconds to happen. An alarm doesn't prevent a fall; often it just lets you know to expect to find someone on the floor.

This. Yes. What's your hospital policy on sitters? Because we can't restrain people in their beds, no matter how much we think that might be protective.

Yup, people fall all the time, you can be right behind them...and thunk, they are on the floor. Just got my mom admitted to LTC. I had a conversation with the DON and said yep, "she's gonna fall" and I chuckled. She looked at my with a funny look. I have worked in LTC for years perdiem. Folks fall.

I said, "she was falling all the time at home, hence one of the reasons she is here. I'm just glad she won't be on the floor for 8 hours". She admitted that my remark was refreshing!

Don't sweat the small stuff. Do everything you can to prevent it, but don't beat your self up about it.

Coming from a patient perspective, I wish it wasn't consuming you so.

My dad fell like 4 times at a facility after having a hip surgery because he was also going through severe DTs from withdrawl and would literally forget where he was or that he could not get up. They even moved him near the nurses station to try and keep a better eye on him. I know there is a whole other side to it I havent experienced yet, but if you did the best you could with what you had, you arent to blame. What matters, in my eyes is that you CARE.

1 hour ago, NutmeggeRN said:

Yup, people fall all the time, you can be right behind them...and thunk, they are on the floor. Just got my mom admitted to LTC. I had a conversation with the DON and said yep, "she's gonna fall" and I chuckled. She looked at my with a funny look. I have worked in LTC for years perdiem. Folks fall.

I said, "she was falling all the time at home, hence one of the reasons she is here. I'm just glad she won't be on the floor for 8 hours". She admitted that my remark was refreshing!

Don't sweat the small stuff. Do everything you can to prevent it, but don't beat your self up about it.

EXACTLY how I felt with my dad. When he broke his hip nobody even knows how long he was alone on the floor and when they said he kept falling at the facility, this was my exact thought. At least he has help and he will be found.

1 hour ago, Kotylynne said:

EXACTLY how I felt with my dad. When he broke his hip nobody even knows how long he was alone on the floor and when they said he kept falling at the facility, this was my exact thought. At least he has help and he will be found.

It was 2 years in the making for her get into LTC but whew! What a relief., We can go and visit..and visit!! Not clean, do laundry, wash dishes, try to wade through paper piles...I can just relax and enjoy time with my mom...its nice.

On 5/19/2019 at 1:32 PM, littlemissBSN said:

I'm an RN at a recently built hospital. It's been tough and hectic trying to get acquainted with the new system that even though there is low nurse:pt ratio. We have barely opened and there is already a fall incident and it was my patient. That patient is a fall risk and I have been particularly watchful of her since she is very impulsive. I only had 3 patients that day and my CNA had 2. As I was doing my rounds, I found her on the floor, I was terrified. Terrified to see her there and even more so when I realized the alarm didn't go off only to notice that it was not even activated when I checked. I was shaking as I helped and reassessed the patient. She thankfully did not sustain any injuries and the family was very understanding.

But it's eating me up. I find this unacceptable and upsetting because this was completely preventable. I've prided myself to be a conscientious nurse, but I'm obviously doubting that now. The fact that we had just opened, that I was the first nurse to have a fall at our facility, and that I had the fewest patient load in my career just doubles up my guilt. I genuinely don't know why the alarm wasn't activated. The bed alarm is working well upon check and I don't want to put fingers. I have no excuse and I take full responsibility for this. My bosses have been incredibly understanding and nurturing, which I'm thankful for. Even then, I couldn't get over it, not yet.

As I've told myself over and over again, this is a learning experience to help me be better and that the most important thing is that the patient was not hurt. For now though, I couldn't help but still feel dejected and cry whenever I think about it. I'm looking forward for the day I'd stop beating myself up over this.

STOP doing that to yourself! You are not infallible. Perfect people do not exist.

The fact that the fall bothers you so much proves you have a conscience. It's ok to be human, stop beating yourself up. If it happened to a nurse friend what would you say to her if she were doing this to herself? You would support her and encourage her to learn and move on. OK, then...Do that for yourself. Self-degradation is not helpful. Be happy she didn't get hurt and be happy that you know you will always check alarms. It just made you a better nurse.

On 5/19/2019 at 1:32 PM, littlemissBSN said:

But it's eating me up. I find this unacceptable and upsetting because this was completely preventable.

Completely preventable? Nope. You don't have that much power. A bed alarm is a warning tool, but even if it alarmed, there's no way to know if you would have been able to get to her in time to prevent the fall. It might be because you were busy with something else or it might be because she fell really fast, but bed alarms are only for risk reduction; they are not infallible.

A few months ago, I had a patient fall while I was in the room. I was on the other side of the room, and turned to see him coming up over the side rail, and could not get to him fast enough. After that, he ended up in an enclosure bed because he was young, fast, impulsive, and actively detoxing.

I get where you're coming from because there's always the "what if" in your mind. But there really is no way to know for sure.

If you hold yourself to a standard of perfection, it's going to paralyze you. Not just in the area of falls, but nursing in general. There will be patients who are noncompliant, and no matter how good your education is, they're still not going to take their meds - it's not you, it's them, and you can't let yourself fall in the the trap of thinking that if you only used the right, perfect explanation they'd fall in line. There will be med errors, because no matter how conscientious we are, we mess up - hopefully, your med errors will be benign. You will miss lab values coming in sometimes or fail to reassess something that was okay earlier. Hopefully, someone else will catch what you miss, but other times they won't, and sometimes you'll catch someone else's error. You have to find a way to make peace with doing your best and avoiding harm, knowing that sometimes you'll mess up, and sometimes things will go sideways, even if you've played by the rules. Nursing is messy. Nothing is completely preventable.