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Patient Safety: We could be the killer!

Safety Article   (12,956 Views | 14 Replies | 800 Words)

Mayjor Wong is a BSN, RN and specializes in Cardiothoracic Nursing.

1 Article; 1,837 Profile Views; 2 Posts

I had a trembling and shocking day yesterday where I witnessed myself how my colleague delivered a shock to my client with a stable rhythm unintentionally when performing the device system check.

Patient Safety: We could be the killer!

It took me a while to come back to writing after a nap that rested my mind that exhausted for the entire busy and hectic week that I have had. I have been thinking for the entire night about thing I have learned after the event that encountered yesterday in relation to the issue of 'Patient Safety'.

I had a trembling and shocking day yesterday where I witnessed myself how my colleague delivered a shock to my client with a stable rhythm unintentionally when performing the device system check. This result my client's heart rhythm deteriorated to a life threatening rhythm 'Ventricular Tachycardiac', although it was still in a perfusing rhythm at that time but his hemodynamic compromised significantly. I would say 'defibrillator' supposes is considering a life saving device. Somehow it could be a device that can jeopardize and lead to fatal if we use it inappropriately. Luckily, we are able to revive and salvage our client after the electrical and chemical cardioversion.

Well, as I said the medical equipment can be a life saving device and it could be a device that leads to lethal. This is evidence in the available data that reported the incidence of 0-6% IABP rupture and cause helium gas or air emboli. In other hand, data also demonstrated that the incidence of pulmonary ischemia, infarct and rupture due to inappropriate placement of Pulmonary Artery Catheter is significantly low where account for 0.2% of probability, however, it is associated with high mortality rate up to 50% if it happened. I would say, sometime the 'tragedy' can be avoided if we uphold the significant knowledge, understanding and skill how to handle the equipment in the right manner. Somehow, most of the time, lots of people still neglected the crucial facts and information which might lead to life of others being jeopardize.

However, my prediction telling me that it changed the entire plan and management for the client significantly because of this event. This was because our primary ICU team physician thought that the client is not doing well with the weaning and condition turned back.

According to the initial strategy and management that planned in 24 hours ahead and during morning ICU round immediately prior the event, the client suppose will proceed with the ECMO explantation in Cardiac OT which arranged by CTVS registrar on call and primary consultant. However, because of the VT event, the plan for explant was change instantly and decided to perform ICU instead as the entire team thought that the client was not stable enough transport to OT. Somehow, the plan for explantation is abandoned as claimed to have family issue of concerned. Well, this could be my assumption, may be there is other reason behind to change their plan that lead them to decide explant in ICU.

During and after the event, I did approach the colleague that involved and talk to her about her action that lead to patient's rhythm being compromised. I understand how she feels, her feeling of fear at that moment and I could forgive her action that lead to patient's life being jeopardize and perhaps can be fatal because I knew that was unintentionally and subconsciously. Somehow, I feel very disappointed and I don't think I can forgive her where she attempted to destroy the evidence of rhythm strip that printed from the defibrillator while I was rushed to get Amiodarone from our unit Omicel medication system.

My dear colleague, frankly speaking I do not have the intention to test your honesty and integrity? But don't try to make fool of me as you still haven't reach that stage. Although you have destroyed the evidence, somehow I still can retrieve back the evidence if I wanted to. Although the defibrillator do not have the data storage card, however, it is equipped with the internal event summary that can store up to 300 events and up to 50 6 seconds strip.

Again, It is not my intention to lower your self-esteem and demoralized you from this event. I know if I forward this issue to the higher authority and management level and you will in the great trouble. Somehow I sincerely hope that you can perform your self reflection and have the self-conscious to learn from this incidence, take this incidence as your learning point and do not repeat it again.

Life is full of choices and you can choose not to learn from this incidence. It is your personal choice, somehow, I sincerely hope that you will learn from it and be more vigilant at work and try not to put your client in life danger. Most importantly uphold the 'safe practice' as simple as that.

1 Article; 1,837 Profile Views; 2 Posts

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K.P.A. has 2 years experience and specializes in mental health.

205 Posts; 4,038 Profile Views

File a full report. You may be the 10th person thinking,

Somehow I sincerely hope that you can perform your self reflection and have the self-conscious to learn from this incidence, take this incidence as your learning point and do not repeat it again.

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44 Posts; 2,106 Profile Views

Not sure where you are going with this article. It was difficult to follow, not sure if it is a grammar issue, or more likely a language barrier? Some of the sentences do not make sense.

Obviously fill out the appropriate paperwork. Sometimes good things do come from such incidents (like perhaps changing your hospital's policy to NOT TO DO A SYSTEM'S ChECK on your various equipment while it is connected to a patient).

I think it should be left up to management how to council/reprimand this nurse. Writing a passive-aggresive tinged letter is not the answer.

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25 Posts; 1,326 Profile Views

"life is full of choices and you can choose not to learn from this incidence. it is your personal choice, somehow, i sincerely hope that you will learn from it and be more vigilant at work & try not to put your clients in life danger. most importantly uphold the 'safe practice' as simple as that." 

so great, now you two know not to do this action again and you two will take this fact to your graves. this information is now unavailable to all your co-workers and all the other medical institutions that they will interact with. so, when the next person does this and kills someone you will have the luxury of knowing that they should not have done so.

i can tell by your writing skills english is not your primary language, but you sound like you are a competent medical professional. so why are you not acting like one? this incident needs to be reported to save others from making the same mistake and killing people. writing a hard to follow letter in this forum is not an acceptable way to get this information out to your co-workers or to any and all medical professionals.

your co-worker panicked and tried to cover her tracks...very bad!

but you now are aware of this little unknown fact and are not correctly publishing or reporting it so it will not happen again to someone else.

it is somewhat safe to say that other person will never do this action again, and that might save a few lives.

if you had done your duty and reported this correctly, maybe a hundred or even a thousand people would never do this action again....

you do not need to be a genius to figure out how many more people would not die then... 

reporting is not just a way to spank people when they are doing their job...

it can change procedures and saves lives... do the right thing.

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1 Article; 8 Posts; 2,702 Profile Views

I am not surprised that someone made a mistake even of this proprtion. I am surprised that "mayjor wong" did not report this as an adverse event. Protecting a collegue who not only almost cost a patients life but who would also destroy evidence is the same thing as being an eyewitness to a nurse giving an overdose of Morphine. Now this patient is going to be labeled as having had an arrythmia that he did not. Your coworker obviously learned nothing from this except she can count on you to keep your mouth shut while you look the other way. What if that had been your parent? I worked in Risk Management and frankly I would be afraid to have you on my staff. You are supposed to be the patient's number one advocate but instead you let your patient down and you set a new low for morality in your institution. If this event happened once it can happen again but you just made sure that there would be no education to prevent anything like this from happening again.

Edited by maggiejrn
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TampaTech has 2 years experience and specializes in med/surg and Tele.

102 Posts; 2,516 Profile Views

I am sorry but this article is very difficult to read and comprehend.

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P_RN has 30 years experience as a ADN, RN and specializes in ORTHOPAEDICS-CERTIFIED SINCE 89.

6,011 Posts; 33,696 Profile Views

The OP lists Singapore as her/his residence so English may be a second language.

I thoroughly agree with the recommendation to make an occurrence report to management and let them do the follow up. Though I have pacemaker not a defibrillator, I know they have retrieved many yards of reports when I go in for a pacer interrogation. Your manager also must know this.

I still don't understand why you are keeping this between the two of you though.

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MassED has 15 years experience as a BSN, RN and specializes in ER.

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pretty specific, don't you think that story might be read by someone you work with, or something that is on here and knows that person, whom he/she confided in? Did you confront the offender and ask why she concealed it?

I had a hard time making out a lot of this, sorry.

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*LadyJane* has 4 years experience and specializes in LTC, wound care.

278 Posts; 9,593 Profile Views

A perfect example of passive-aggressiveness. What happened here is a mistake. It may have been a mistake caused by your collegue's, or it could have been a systems error. It should be reported so that your facility knows what happened, and also so that what caused this to happen can be corrected.

To simply keep this to yourself, so that you can hold it over her head, is not right, and indicates possible presence of lateral violence.

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AmazingGracie specializes in L&D, ER, PACU.

13 Posts; 1,178 Profile Views

What??? Are you serious???? A patient was actually defibrillated during a routine monitor check?????? You can not be serious. If this did in fact happen, at least have the decency to report the incident. There is definitely a learning opportunity here. :confused: This is a sad state of affairs.:eek:

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diane227 has 32 years experience as a LPN, RN and specializes in Management, Emergency, Psych, Med Surg.

1,941 Posts; 12,166 Profile Views

How is it that a piece of equipment was attached to a patient during a routine check? Are you serious here? This is something that never should have occurred. If you have the defib attached to the patient on stand by then that is NOT the right time to be doing the equipment check to see if it works. You MUST make a formal report of this incident because it caused harm to the patient and changed the plan of treatment. And in addition, who was standing around while she was performing this "task"? Did anyone happen to notice what she was doing before she did it?

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tanjaccurn has 7 years experience and specializes in critical care.

11 Posts; 1,634 Profile Views

I think the author of this particular article needs to hire a proof-reader......the English and grammar are atrocious!!

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