Tony35NYC

First of all, thanks to everyone for your encouragement and support. I wanted to update you with the latest developments, and you may be surprised. But, before I get into any of that, the good news is that the 'near-miss' patient is doing very well since his second surgery, and he is still being kept in CV even though his condition has been upgraded to stable. Now for the other stuff. Some of you raised questions about the outcome of the incident so I am going to fill you in. They had pulled two nurses from the floors that day to sit at the monitors because they were short on monitor techs to cover the shift. Then they split up those nurses' patients among the other nurses, and that's one reason each nurse ended up with so many patients on the previous shift. At the change of shift, they simply passed on the mess to us. I had to sit through an hour-long meeting with my nurse manager and listen to her hypocritical B/S. On the one hand she's telling me I'm a great nurse, and at the same time she's telling me that I'm careless and unprofessional and that my bad judgment could have resulted in the patient's death. No mention of CVICU for transferring out an unstable patient, no mention of the charge nurse assigning an unstable heart patient to an inexperienced agency nurse, no mention of the fact that we were working under impossible conditions, no mention of why the charge nurse did nothing when I asked for her intervention with the patient assignments... Then she had the nerve to ask why I was just sitting there staring at her and not saying anything. Its just that I couldn't think of anything to say at the time that wouldn't be rude. Notwithstanding, I was given both a verbal and written reprimand, and the paper says that the document will go on record even if I refuse to sign it. I am being suspended for 2 days without pay, and told that I have to attend an EAP thing on time management and prioritization skills within the next 30 days and bring proof of attendance back to the nurse manager, and also that I have to demonstrate "improved communications skills" with the charge nurse regarding patient assessments (to be signed off by at least two different charge nurses). If I do not do these things within the 30 days I will again be suspended without pay and, possibly, terminated! I am unfazed by these threats. Our PCCU is comprised of three adjacent units, each with 40 beds. Each unit is supposed to have its own charge nurse, its own monitor techs, and its own nurses. But they have no staff, so what they've been doing a lot lately is using one charge nurse to cover all three units on each shift, and she/he spends the entire shift running back and forth between the units trying to keep on top of things. Sure, the charge has report on which patient is in what room, and who's on which drips, etc. but even a super chargenurse can't cover 3 units with 120 patients! Also, they never have enough nurses to properly staff all 3 units so they frequently pull nurses from one area to staff another, and whenever they do this no matter how many other patients you have, if your unit is the one that is losing a nurse every other nurse on that unit has to pick up another patient or two. You can protest and refuse all you want, but they don't care. If you complain they say you are not a teamplayer and you are blacklisted as a troublemaker (no end of year bonus, and a paltry salary increase). I've seen it happen. Another bad thing is that they have one nurse manager overseeing all three PCCUs and this woman has no management skills whatsoever. During the past several months she's hired a number of assistant managers, and all but one of them have quit after only a month or so. (The one assistant manager who's still there is a joke. She does nothing but sleep whenever she's on. For the first few hours she acts as if she's really busy then the next thing you know she's heading to a private area wrapped from head to toe in a sheet and complaing that the place is so cold. Then you don't see her again at all until about an hour before the night shift ends, and her only concern is that everyone has written report so she can leave on time.) As for the manager, all she does is attend meetings and go off to seminars, then she comes back and holds staff meetings with all these grandiose ideas that never come to fruition. Staff has grown so weary of her lies and deceptive promises that no one takes her seriously anymore, and she just sits there and allows the situation to get from bad to worse. This hospital is huge, and they recently did a LOT of expansion to it. The huge lobby with Italian stone tiles, a marble fountain, and exotic foliage. The new ORs, units, and private rooms are all so big and fancy that you would think you are in the Waldorf Astoria, and I'm not exaggerating. Some of the private rooms have well-decked guest suites attached so friends and family can stay over. The board of directors went all out with the construction of this new cardiac wing, and you can actually see the millions that went into it. There isn't a single patient or visitor who comes in there since it opened who hasn't complimented the ornate design, state of the art equipment, and furnishings. Even the paintings on the walls cost a bundle. All of this was done to attract more 'upscale' clients. And they have been aggressively marketing the hospital's specialty cardiac services to "uptown" folks who can either afford to pay big bucks or have very good private insurance. The people who run this joint couldn't care any less about quality care as long as they are raking in bags of money from the patients. But all this prettiness doesn't change the fact that the place is a deathtrap being run by a board of money-loving hoods. They recently closed down a number of the med surg, ortho, and psych units to make way for highly specialized cardiac services. Then they brought on more high-profile cardiac surgeons because they are trying to increase the number of open-heart and cardiac cath procedures to make bigger profits. The problems began because they now have these huge cardiac units with too many patients and nowhere near enough nurses to staff them. The new CVICU is so fancy and high tech that its like something out of a Star Trek movie, and it costs a ton of money to stay in there. So, its not good business for them to keep people in there too long if they don't have good insurance or the cash to pay, and what they've been doing is ushering out the HMO and no-insurance patients faster to the step-down units. There are even certain cardiac surgeons who demand that their clients be given preferred room assignments, and because these surgeons are the ones who are bringing in the money they always get their way. So even if a CV nurse suggests that a patient is too unstable to leave the unit, whether the patient stays there or not almost always depends on the patient's surgeon, $$$, the type of insurance the patient has, or how badly another high-profile surgeon wants the bed. All things considered, I've decided that I can no longer continue to work at this place. I am going to take some time off to think about whether I really want to continue in nursing because I keep hearing that this type of situation is the norm almost everywhere. In any case, I plan to put in my notice. Before I became an RN I worked as a manager in a cut-throat, backstabbing corporate environment but even that pales in comparison to this. At least then I would never repeatedly find myself in ridiculous situations where I could unreasonably be held responsible for someone's death. Thanks to everyone for your advice, I have detailed notes on the incident when I went on shift that night, and I have an appointment to see an attorney later this week. I also plan to send an anonymous letter to JCAHO about this hospital, and I hope they get a surprise visit sometime soon.

This week I got in trouble for a near miss. Well... myself, the secretary, the PCA, and the nurse I took report from. We were all written up for it, but I was told that it was primarily my fault. This is a long post, but for anyone who has the time to read it, here's what happened: I was floating to PCCU and this particular patient was a fresh post-op open heart who had been transferred in from CVICU a bit early because they needed the bed. In my opinion, this patient should not have been moved from CV because he was still very unstable, on multiple drips, still had respiratory issues, still retaining a lot of fluid from the CHF, and had two lateral and one medial chest tubes draining sanguinous. He was NSR on the monitor but he had had 5 bypasses, and he came over with the pacer set at 50/20. The agency nurse who gave me report on this patient neglected to tell me quite a few important details about this guy. She was very angry and in a bad mood because she had had a very rough shift. All her assignments were pretty complicated cases, she kept complaining that she had to be literally running from one room to the next the whole time and how she couldn't wait to leave and that she was never coming back to work on this unit. A number of things were strange about this whole event. First of all, the hospital has a policy to not give fresh open heart patients to agency nurses, but in this instance they did because they had no one else. As I would later find out, this particular nurse did not have any experience with cardiac patients and she did not follow some of the post op protocols (which later caused problems for me)---and more serious problems for the patient. The other thing is that PCCU has a policy to not give more than three assignments to a nurse who has fresh heart patients, especially when they are on titrated drips, but in this instance, they gave the nurse six assignments, and she apparently did not know that she should have refused. In my opinion, they shouldn't transfer any post op heart patient who's on titrated drips to stepdown because they need much closer monitoring than you can give when you have three or more other patients to take care of. During report, she told me that the patient was stable (which was not true), that his surgical dressings were dry and intact (which was also not true), that his o2 sat was good (which was also not true), and that all his drips had been D/C'd except for a bag of LR which was going at 75cc/hr. I was to take over all her other assignments as well, and I spoke to the charge nurse about this because I didn't feel comfortable about having six patients and a fresh heart. Her response to me is that we were really short on staff, and since the patients are all stable we would play it by ear and she would try to make some changes if anything develops. My first big mistake was to agree to this. Under any other circumstances I would have refused the assignments and gone back home, but she warned me that I had already taken report and that if I left she would write me up for pt abandonment. Only a few minutes into the shift, one of my other patients went asystole and we had to rush in there to run a code. Fortunately, we were able to bring the patient back, but by the time we stabilized the patient and moved him to the ICU I was nearly 2 hours behind with my assessments and chart reviews. By the time I got around to doing my assessment on the open heart patient (who I decided to see first) I immediately realized that this patient was also going bad. The respirations were labored and I could hear the fluids on his lungs even without using the stethoscope. The continuous pulse ox monitor was still attached to his finger but the machine was off (it was not plugged in and the battery had died). He was supposedly on 5 liters of 02 via NC (which wasn't even humidified, by the way), and when I got the oximeter on again his sat was 80, and only God knows how long it had been there. (The nasal canula he was supposed to be wearing was on his forehead). Ok, so I rush to get the respiratory issue under control (called in RT, etc.). RT eventually had to put a nonrebreather on him, and protocol states that if a patient is unstable enough to need a nonrebreather they must be transferred to ICU. The guy was still not doing so good, and the anesthesiologist from the respiratory ICU was seriously contemplating putting him on a vent, but thankfully, that wasn't necessary. Of course, after I notified the MD and began to prep the pt I was told that there were no ICU beds. In emergency cases such as these, PCCU is supposed to implement ICU protocols and we had the equipment at hand so that was done. But, here's another big problem: ICU protocols have been initiated, but I still have six patients, and neither the charge nurse or the nursing supervisor is returning my calls because they are too busy fighting fires with serious staffing and other issues elsewhere. Then I start to check out other things on the pt. The dressing on his chest was soaked through and it turned out that the guy had frank, active bleeding from the sternotomy. Applied some pressure to the site, reinforced the dressing and put out a call to the surgeon. But it didn't end there. The guy was also a new onset diabetic with hyperosmolar issues. I immediately went to check the blood sugar because he seemed confused and aggitated and I suspected that the blood sugar might be low because he had been on an insulin drip (which the nurse had told me was DC'd). An order had been written to D/C the insulin drip and switch the pt to a sliding scale with regular insulin and to change him from LR to D5 1/2 (neither of which had been implemented), according to the MAR and the diabetic flow sheets the nurse from the previous shift had been doing the blood sugar checks AC & HS instead of Q2 according to the protocols. Even though the MD had incorrectly written the order for AC and HS she should have known better because the patient was still NPO so an order for AC BS checks makes no sense. Furthermore, the insulin drip protocol overrides written orders for BS checks in all the units. The guy's BS was in the 30s so I immediately shut off the drip and pushed D50. He was also complaining of pain, but I didn't want to give him any narcotics right then because of the respiratory situation. And, it gets worse. When I went to check the BS, I found that the patient was not wearing an arm band so there was nothing to scan into the glucometer. I eventually found the ID band and the blood arm band on the window ledge (he had been type and screened for blood and he needed 2 units to replace blood loss during surgery). I later found out that the nurse had cut the bands off because his previous IV site had infiltrated and his arm had swollen up so much that the bands were too tight. Yes, she did order new ones from admitting, but when they sent them up she grabbed the wrong ones from the nurses station and put them in the patient's room. So, in my haste to scan the arm band to check the BS I didn't immediately notice that it was the wrong patient name. She also did not give the second unit of PRBCs that was ordered. Thank God, I caught the mistake with the wrong blood ID band during the ID check for the second transfusion otherwise I would have transfused the wrong blood type, and the poor guy probably would not have survived a severe reaction. The pulmonologist ordered diuresis with 80mg of IV lasix stat. When I went to give it I realized the guy did not have a foley in. How could you have an unstable surgical pt like this in a critical care unit with no foley? I began to wonder where she was getting the information she had been recording as his urine output on the nursing assessment sheet, then I figured she must have made it up because this guy was certainly in no position to use a urinal. Furthermore, the urine output she had recorded could not have been correct because if this guy had been NPO and receiving only 75 ccs of IV fluids an hour and putting out that much urine over the past several hours there's just no way he could still have so much fluid on him. Also, when I checked the post op orders I found that his AV pacer had been incorrectly set. And here's another big one: remember the drips that she told me were off? Well, not so! The guy came from CV on a titrated nitro drip, and not only could I not find any information on the flow sheet to prove that she was titrating the drip but it was actually still going @ 5 mics, which is exactly where it was set when he was transferred from CV hours ago. Also, the PCA who did the vital signs did not tell me his BP was critical low, in fact, I couldn't even find her! When I checked it myself it was 60s over 40s. There were so many other things that were either not done or done incorrectly that by the time I got around to checking and fixing and assessing everything to prepare to send the patient back to the OR it was now almost 3 hours into the shift and I hadn't yet seen any of my other patients (except for the code) and all my meds were passed very, very late. I don't know what I would have done if one of the other patients had crashed that night. I could just imagine myself explaining to the board of nursing why I had not done any assessments on my other patients after being on shift for more than three hours! Of course, an incident report had to be done, and administration is saying its primarily my fault because I should have done my initial assessment on my fresh heart patient sooner. I accept some of the responsibility, but I disagree that it was my fault. How do you rationalize switching priorities from responding to a code situation if you are made to believe in report that your other patients are stable. Also, why are they trying to throw all the blame on me when they are also at fault for giving this patient to a nurse with absolutely no critical care training or experience in the first place? Also, the charge nurse later denied that she and I had had a conversation about changing asssignments according to patient acuity. She instead said that I failed to show good professional judgment because I should not have accepted the assignments in the first place. I realize she was covering her butt, but I think its disgusting that she just flat out lied like that. Instead of looking at the whole picture and talking about how to prevent something like this from happening again, the whole incident deteriorated into one of fingerpointing and accusations. If this patient had died its obvious they would have tried to pin the whole thing on me. They would still have their hospital, but its very possible that I could have had charges brought up against me, that I could get sued, or that I could even lose my license. Now I don't trust anyone when I take report. Perhaps some of you could tell me what I could have done differently.

Palm Beach Community College also has an RN program that you could look into if you decide to move there. http://www.pbcc.edu/programs/programsheet.asp?id=73 Palm Beach county is an ok place to live, but I would not recommend the City of West Palm Beach as a preferred location to live or to send your kids to school.

The cost of living in South FL is not as high as it is in SoCal but it is still high if you consider that nurses earn far less in Florida than they do in California. There are hospitals in south Florida that are paying RNs as low as $18.50 an hour, but I've heard you can do a bit better if you work agency or contract. Real estate in south Florida is still very expensive and the cost of property insurance is going through the roof because of all the disastrous hurricanes they've had down there. Also, in south Florida there are no unions and they don't have patient ratio laws like the one that exist in California.

I think its great that you acknowledged your mistake and immediately took action to protect the patient. Your colleagues are correct that human error is always a possibility and we can never be too careful. I always check for compatibility issues when I have a patient on multiple drips. Even if the nurse from the previous shift had ran them together with no problems I don't assume anything. Its a habit I got into after being chewed-out (BIG TIME) by a clinical instructor who once deliberately stood by and watch me almost make a similar mistake when I was a student. If you're taking care of a lot of patients at the same time and you find yourself running too fast or becoming overwhelmed, when it comes to meds make yourself stop and go over everything again before you give it. I know some people will say this is not good time management but I believe in 'better safe than sorry'.

Have any of you read this article? http://news.yahoo.com/s/ap/20060402/ap_on_he_me/easier_heart_valves;_ylt=AqI7syPKaTOQMcJmO59uR7Ws0NUE;_ylu=X3oDMTA3czJjNGZoBHNlYwM3NTE-

When you buy a Littman, there is a little form that comes in the box that you can fill out and send away to the 3M company for them to engrave your name and it costs about $7. If you can get the engraving done from another source for free then that's the route to go. However, this will not prevent someone from cutting off the name tag if that person is determined to steal your stethoscope. To be safe, keep it on your belt clip or around your neck at all times.

I just want to add that speed should not be a top priority for a new nurse. I believe in taking the needed to develop your own pattern of efficiency as you gain experience rather than to try to get everything done quickly. Its always better to be safe than to be fast because its too easy to make serious mistakes when you're new. You are going to find that as you get more into your practice everything becomes more and more familiar to you, and things that you used to second guess yourself about will begin to flow naturally. A lot of it comes with developing good time management skills and knowing how to rationalize how you prioritize the care you are delivering to your patients. For example, when you take report keep a mental picture of which patients you need to see first and anticipate which ones you will need to spend more time with during the shift. If you're working on a specialty unit, use your free time to look up the more common pathophysiologies that are seen on the floor. Familiarize yourself with the procedures, the protocols, the diagnostic tests, and the drugs that the physicians are likely to order so that you know exactly what to do, when to do it, and how to do it safely. When I was a brand new nurse on the floor I used to watch how the experienced nurses did their thing, and I learned a lot just from doing that. Pick up the productive habits and ignore the rest and you'll be functioning like a pro in no time.

If you haven't yet maxed out your financial aid entitlement apply for as much free money as you can get from the feds, the state, and scholarships before you take out any student loans. Don't take for granted that the financial aid office at your school will tell you about all the opportunities out there. They wont. Go to the nursing department and ask them to give you information about scholarships and grants specific to nursing. And, even if you are not in a traditional ethnic minority group still apply for minority scholarships because I found out half way through nursing school that, as a male entering nursing, I qualified for minority scholarship money that I assumed I could never get. Since you are serious about making a career switch, as someone suggested earlier, apply for a job at a large hospital and get them to pay for your nursing education. Most hospitals offer such a program to their employees in exchange for a work commitment afterwards. The commitment is usually only for a couple years, but the time goes by quickly, and once you have some nursing experience under your belt you can go whereever you want to from there.

Even if you have multiple piercings, lose the earings. One pair of them should be ok but anything more will look gaudy. Go light on the makeup and perfume. According to Careerbuilder.com, too much of these things is not good idea for a job interview. Good advice about dressing professionally. I've read that the classic look is the one that makes the best impression so a suit would be ideal. Get there a few minutes early in case you need to fill out any paperwork before the interview, and bring a couple extra copies of your resume in case more than one person will be interviewing you. Read up a bit about the hospital so you have some idea of what new things they are doing in the community and bring a list of questions to ask about the hospital, staffing ratios, how your performance will be evaluated, how long your preceptorship will be, etc. You want them to think that you are really interested in building your career there so salary and benefits should neither be the first nor the only things you ask about. Also review some critical thinking processes and the typical rationales. It is not uncommon for nurse recruiters to throw scenarios at you and ask what you would do were you to find yourself in certain situations. Also, don't try to act like a know it all, its always safe to sell yourself as a team player who's willing to learn. They know you are new so they don't expect you to talk about your range of nursing experience. There was an excellent post about all this stuff in the grad student nursing forum last year do a search there and you will find a lot of great advice about getting ready for interviews.

I do not put NS into the vials. Ativan is viscous but you can still easily aspirate all the contents out with a blunt needle. I never push air into the tubex because its too easy to blow all the contents out the other end...then you have to waste and start over. I always draw up just enough NS to dilute the Ativan 1:1 then I push it slowly over 2 to 3 minutes.

You also have to be careful of the assignments that you are given and know when to refuse, especially as a new and inexperienced nurse. If something goes seriously wrong and the patient is harmed not only can you be sued but you will also be blamed for attempting to deliver care that you were not adequately trained to give. You also always have to be careful, even when the task you're performing is within the scope of nursing practice because you can make a mistake, especially when mixing certain meds or improperly titrating certain drips. And, even if a medication is ordered you have to use good judgment to know when giving it will cause harm to the patient (i.e. certain doses of a seemingly harmless med can be dangerous for renal patients, or may be incompatible with some other drug that the patient is taking, etc.) I've seen cases where there were numerous consulting physicians writing conflicting orders for a patient, pharmacy may not catch the mistake in time and you can never assume that it is safe just because a doctor wrote it. Even if the physicians write bad orders YOU are the one who will be blamed because your are the one who gave the medications to the patient and the BON will say that you that you are an unsafe practitioner because you should have checked. This is one reason I will never let medication aides pass anything to my patients, not if I'm to be held accountable for the consequences.

That woman is not only rude and unprofessional but evidently a mental case as well. Maybe she's just jealous of you. I would quietly look for another job then put in my notice. There are too many nursing opportunities out there for anyone to put up with this type of nonsense.

Last year they gave out scrub shirts with the nurses' week logo and slogan on it. Considering the pitiful and pathetic gifts I've heard were given out to the nurses here in previous years I very surprised at the high quality of the shirts, but that pales in comparison to the expensive bash they're putting together for Physician's Day.

Just about everything that is done on the day shift is also done at nights. Just because the patients are supposed to be in bed doesn't necessarily mean all of them are sleeping or even that they're in the bed. Sometimes (many times) they keep you running ALL night: the sundowners without sitters who start to act up, the ETOH-ers and substance abusers who won't settle down no matter how many PRN drugs you give them, the supposedly stable patient who suddenly develops lethal arrythmias or respiratory problems, the ones who wake up confused in the middle of the night and pull out their IVs and start bleeding everywhere, code browns---often, with no PCAs to be found anywhere to help you do anything, non-stop new admissions, and, worst of all, the dreaded 'code blue'. The list goes on and on. You still have to do your shift assessments and pass your round the clock and PRN meds. Even if the patients are asleep you have to wake them up to give meds or do treatments at the time ordered by the doctor. You have to do your charting, and then you have to do your 24-hour check-off on all your patients' charts to make sure that everything that was ordered has been done. Where I work the action is non-stop all day and all night. Its a regular thing for us to prep a patient stat for a procedure, a diagnostic test, or even for the OR in the middle of the night if the patient starts to go bad and the physician orders it. And some of the rooms here have guest suites where the families can stay overnight, and sometimes its not that different from working during the daytime at all. And the nursing supervisors are like the wind---they're everywhere, looking for even a glimpse of a vacant bed so they can send more patients. I hardly find myself with enough time to finish passing early am meds, hang drips, do blood sugar checks, etc. Before you know it its 5am and the docs are in the unit grabbing up all the charts and clipboards and asking questions. Then the day crew shows up and everybody wants report now.