Patient stable when I left

[yourbee4eva]

I recently had a situation occur where a patient that I cared for during my shift was airlifted to another facility r/t a pneumothorax during the next shift. While I cared for her, the vitals were stable and oxygen saturation above 90%. The initial diagnosis was pneumonia. Apparently the doc was upset that I did not notify him of "how bad" the child was during my shift. However, she was stable the entire time and I documented my vitals as such. I did have to place her on oxygen once she fell asleep to maintain the sat greater than 90%, but this is generally a normal intervention with pneumonia, and the MD gives orders for this prior to it occurring. Respiratory also assessed the child when the oxygen was initiated. I guess what I'm asking is... should I be worried that legal action could be taken against me since the child got worse within the hour after I left my shift? The nurse who followed me said she was not maintaining her sats at the time that she did her initial assessment. She tried a few interventions herself before the child was airlifted (none of which helped raise oxygen level). Another note - the mother was with the child the entire shift and never expressed any concern of worsening condition. I know a pneumothorax may happen quickly, but I'm so worried! It's like she got worse right at shift change. I cannot quit thinking about this child.

[Ruby Vee, BSN]

Murphy's Law has several corollaries, and one of them states that "Your patient WILL get worse at change of shift -- between the time you last looked at him and the time the next nurse does her assessment." It's happened to me a bunch of times. I don't know WHY it happens, but change of shift seems to be the most dangerous time for some patients!

[NotReady4PrimeTime, RN]

Ruby's right. I've lost count of the number of codes we've run to at change of shift, and how many times we come out of the staff room at 0700 to find a crowd at one of the bedsides on the unit, the crash cart nearby. Kids compensate so much better than adults do and because in smaller children, their breath sounds are referred all over the place, it's possible to think you hear normal breath sounds on a lung that's completely collapsed. I think there's too much emphasis placed on "legal action" for relatively benign occurrences. A pneumo is bad, sure, but a potassium overdose is far worse. When bad things happen, take a second to think about what a reasonably prudent nurse would have done in the situation, and if that's what you've done, you're fine. So don't worry, this family isn't going to hunt you down and bankrupt you.

[liberated847]

As a flight nurse I always get the "I just got this patient" or similar excuses for a poorly kept patient when I go "rescue" them from some ICUs. I notice that many times there's marked differences between what's charted and reality.

[hunnybeeRN]

Children can have rapid changes. All peds nurses realize that. It is quite possible there was a change in condition from your last set of vital signs to the oncoming nurses initial assessment. I once had a physician tell me that "each time we go into the room, we potentially assess a different patient." He was referring to his daily physician rounds, but it's true of nurses too.

My first pneumo patient was breathing in the 80's with sats below 90 on my first assessment. I had received in report that they were stable. I honestly didn't have time between frequent assessments, calls to the physician, and stat orders to worry about whether or not the child was stable a couple of hours before. I haven't questioned it since either. I have to trust in the skills of the nurse who had the patient before me and deal with the patient condition that I personally assess at the time I care for my patients. Just like if it wasn't done you can't chart that it was - if I wasn't there, I can't tell you that they were different than what was reported.

Don't stress it. As for worrying over the legal ramifications...if you do that every time a patient goes bad after you've had them, you will burn yourself out very quickly. Some things you have to just let go, study what you did wrong (if anything), process the situation, learn from it, and improve from there.

[rnsrgr8t]

Kids are notorious for compensating for a long time and then, when they crump, they crump FAST. Seen it happen so many times. Only thing you can do is honestly asses the day and if you think you assessment and vitals were accurate, then you did all you could. I will tell you to trust your gut. Over time, you tend to get a 6th sense that something is not right, even when their vitals are stable. You watch those kids very closely and inevitably, they do end up crumping. If you have a more senior nurse you can trust on your unit, see if they will sit down with you and with this patient's chart to review your notes and see if you missed anything. Most likely, you didn't.

[caliotter3]

You are only responsible for your patient while she is under your care. If she was stable for you, she was stable. All the worrying in the world won't change that fact.

[meanmaryjean, DNP, RN]

Pneumos happen quickly and cannot be predicted. If your kiddo had a major coughing spell- that could have been enough to do it.