JA89

As far as I know, I'm the only one of the team that night that lost a moments sleep over it. Aside from the fact that the other RN on shift was convinced that we "drowned" him by pushing fluids while he had zero urine output and already on fluid overload

I totally understand what you're saying. I've not denied for one minute my lack of judgement in not going straight to that room. Yes, there were many comorbidities and other factors that contributed to his death. And chances are that a shot of d50 five minutes faster wouldn't have saved his life at all. No doubt he was circling the drain and deteriorating fast. What I'm having trouble forgiving myself for is the fact that I did not take the cna seriously when she told me the pt was not responding. She was very inexperienced (although so was I at the time) and I assumed she didn't recognize the symptoms of hypoglycemia, and it was not an immediate emergent situation that required me to run full speed to the pts room. That taught me a very hard lesson about assuming anything in the medical field. I'm not so much questioning whether I was right or wrong in my actions that night; I know I made a mistake. I suppose the main thing I'm struggling with is whether I am obligated to report myself to the state board for negligence on my part, whether it caused the pts death or not.

I have to admit, part of the reason this bothers me so much is spiritual. As I mentioned in an earlier post, I am a committed Christian man. And my fear is that if my hesitation, or distraction with a cell phone, In some way contributed to that mans death...I just simply feel responsible. It seems to me that other nurses have lost licenses for mistakes like that, and for me to continue practice and get off Scot free would somehow be dishonest. It's just something I'm slowly working through. But again thanks for all the encouraging comments.

Just curious, what is your opinion? Just wondering how you disagreed with the rationalization as you said.

I'd like to thank all of you for your supportive comments, they have helped quite a bit in the way I look back on this case. As to why the CNA did not recognize the emergency, that is a question I've asked myself countless times. She was very inexperienced. To be honest, she probably didn't even think to check for a pulse. Either that, or the patient was still alive when she left to notify me, and he coded in the 8 to 10 minutes between then and when I walked into the room. To be honest, that's been my biggest hang up. But thank all of you again

@westieluv, you make several excellent points, many of which I have considered in the past. He was on telemetry, but in our small town rural hospital the equipment was extremely old and unreliable. Many RNs there paid no attention to its read outs anyway. Half the time the telemetry would lose connection without warning. With what I know now, that man needed immediate dialysis and a bed in an ICU. Not a med surg floor at a small country hospital that was understaffed and underresourced. One of many reasons I'm thankful to no longer work there

Thanks for the feedback. Every one of you have made valid points, and some encouragement. I feel sure I am not the only RN who has ever made a mistake, or felt guilt over a patient outcome. And I must admit the fact that the pt was cool to touch led me to believe some time had passed since his coding. It's simply a guilt issue. I am a Christian man, and integrity is important to me. I never reported my concerns to my administrator then(although I have now) and it seems clear she would not have even considered reporting my actions to the board. So I am not sure why I'm tempted to do so myself. Perhaps a way of soothing my conscience. But at the risk of sounding arrogant, I would say I am a much better RN now than 4 years ago. I think my best solution is to continue counseling, and continue my career. However, this is one mistake I will never forget. I hope possibly some younger new nurses read this, and learn from my mistake

I've had one visit with my EAP at my current hospital. The small hospital I worked at when this happened closed operations some time ago. To the honest the appointment was very unhelpful. His first advice was simply; well do you think the guilt would go away if you quit nursing? He totally missed the point. I enjoy helping people, would like to further my career to nurse practitioner school, but I have to find closure on this or it's going to ruin me

Just in need of feedback from other experienced RNs on this one. I've been a nurse for about 4 years, working mostly ER. I've seen some bad things, but one case still haunts me. It was roughly three years ago. Had a pt who was 50s-60s in age, obese, diabetic, high blood pressure, and if I recall correctly some coronary disease as well. He was admitted to the floor at my small rural hospital. I worked nights, and our only staff was me, one other nurse, and a cna. This pt was admitted with a diagnosis of acute renal failure. I mean absolutely zero output. The docs were pushing fluids on him at the time, which I found odd since he was unable to diurese whatsoever. Because of the renal failure he was unable to rid himself of the metformin buildup that had acquired. Due to this, his blood sugar would tank anywhere from 25-50 every couple hours or so, and a shot of d50 would be required to normalize him. He would present with the usual hypoglycemic symptoms; confusion, slurred speech, or just grunts and moans. Over the shift I gave him d50 about three times, notifying my doc each time. Well about midway through the night, me and the other nurse were working on an ER pt. Our cna had made rounds and came back saying, "'mr. So and so isn't responding to me". I naturally assumed she meant he was displaying hypoglycemic symptoms again. I walked back to the floor, and went to my med room to chart the dose I was about to give and prepare the d50. It was at this point I became distracted by something on my cell phone(I know, huge mistake). I read something on my phone for probably 4 or 5 minutes, then proceeded into the pts room. When I arrived I knew something was wrong. The pt was cold to touch and had no chest rise. No pulse detected. I called a code, but we were unable to save him. For three years I've wrestled with guilt over that situation. I just feel I didn't move fast enough. I know he had other comorbidities that could have caused his death, and for all I know he coded well before we ever found him. My biggest fear is that the man coded due to severe hypoglycemia while I was wasting time reading something on a cell phone for those few minutes. I can't help but feel responsible for his death. Can anyone give me some advice here? All my coworkers and old administrator tell me it wasn't my fault, it was just his time, let it go and move on. I just can't seem to do that. I'm to the point of guilt that I want to call my board of nursing and report myself. I'm just desperate for advice here. Can anyone help me?