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.
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.
But it's eating me up. I find this unacceptable and upsetting because this was completely preventable.
As much as hospital administrators, insurance companies, and the CMS would like to think, falls are not 100% completely preventable. Yes, a majority of falls ARE preventable. But you can do everything right, have every safety measure in place, every risk factor negated or controlled...in short, do everything possible to prevent a fall short of restraining the patient to the bed (and then that's a whole other road you don't want to have to go down), and there's still a chance a patient will sustain a fall.
So unless you were truly being negligent with your patient's care, stop being yourself so much. The patient wasn't injured, which is good. Learn what you can from this and move on.
Unless your patient knows how to shut off their bed alarm. And you'd be surprised how quickly many of them pick up that trick.
No doubt! People with advanced dementia that don't remember much beyond their own name can figure out how to turn those darn things off. It's pretty amazing actually.
How was it supposed to be prevented? I was walking a patient down a hall, arm in arm, and down he went, and took me with him. Patients fall like rain drops in this field, for any reason and for no reason. Alarms do not prevent falls. They sometimes cause falls. And they certainly agitate almost all who hear them ringing. Bed/ chair alarms in some facilities are seen as restraints and no longer used. I love those facilities.
turtlesRcool
718 Posts
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.