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Hi everyone,

I am a BSN prepared RN. About a year out of school I was working at this horrible LTAC hospital. I reported to work one morning to receive report from the charge nurse because the night shift nurse decided to

leave early. On that day I had 6 patients that were acutely ill. One pt I was taking care of was admitted for copd. THIS WAS ALL I GOT IN REPORT FROM THE CHARGE. Being the type of nurse I am, I checked the chart and read my patient HX. The only other hx was that the pt had GERD. Upon assessment I noticed that the pt blood pressure had been running in the 80's to 90's with tachycardia. This had been going on for 4 days. The doctor ordered fluid for this pt in which he was already on. The pt had been recieving immodium for diarrhea scheduled while he was there. The pt did inform me that he was still having loose stools. This pt denied any nausea or vomiting or abdominal pain. The pt also was recieving Questran. During the shift after lunch, the pt abdomen became distended. The doctor made rounds and was aware. He wrote an order to stop QUestran and in his progress notes he wrote pt with deyhdration-give fluids, psuedomonas colitis-check stools for c-diff and distended abdomen related to psuedomonas colitis-stop questran and see if this improves. There were no results in the chart that stated pt was positive for pseudomonas colitis. There was an xray ordered for kub the day before w/o any results in the chart. The doctor orders was followed and pt was not in any distress. After dinner, I was informed that my pt was vomiitng by a tech. I and the charge nurse nurse went to the room to find this pt in distress and vomiting. We immediatley called a code. This pt died. I am very depressed because this happened very fast and when he did show signs of worsining condition, it was too late. I feel has though this could be my fault and loose my license. Later during the shift another nurse found a kub result showing that the pt had a mild ileus. At this hospital, the results are always called in. Evidently the results was called in to the night nurse and she did not report. The doctor or I had not seen the result. I have been very depressed and discouraged wanting to quit nursing after this. I feel like a victim. I have convinced my self that there is no way the family is not going to sue. I have not heard anything or received a letter yet but I can't live my life wondering. I have worked so hard for my career and it seems as though I have failed. Is this my fault!!!!!

:o

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It doesn't seem as though that this is your fault. It is the NIGHT NURSES fault for not reporting this. How could you or the doctor know what to look for if she did not put it in the reports. I would immediatley let this be known so that you wont be the one to blame.

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Specializes in Trauma ICU,ER,ACLS/BLS instructor.
Hi everyone,

I am a BSN prepared RN. About a year out of school I was working at this horrible LTAC hospital. I reported to work one morning to receive report from the charge nurse because the night shift nurse decided to

leave early. On that day I had 6 patients that were acutely ill. One pt I was taking care of was admitted for copd. THIS WAS ALL I GOT IN REPORT FROM THE CHARGE. Being the type of nurse I am, I checked the chart and read my patient HX. The only other hx was that the pt had GERD. Upon assessment I noticed that the pt blood pressure had been running in the 80's to 90's with tachycardia. This had been going on for 4 days. The doctor ordered fluid for this pt in which he was already on. The pt had been recieving immodium for diarrhea scheduled while he was there. The pt did inform me that he was still having loose stools. This pt denied any nausea or vomiting or abdominal pain. The pt also was recieving Questran. During the shift after lunch, the pt abdomen became distended. The doctor made rounds and was aware. He wrote an order to stop QUestran and in his progress notes he wrote pt with deyhdration-give fluids, psuedomonas colitis-check stools for c-diff and distended abdomen related to psuedomonas colitis-stop questran and see if this improves. There were no results in the chart that stated pt was positive for pseudomonas colitis. There was an xray ordered for kub the day before w/o any results in the chart. The doctor orders was followed and pt was not in any distress. After dinner, I was informed that my pt was vomiitng by a tech. I and the charge nurse nurse went to the room to find this pt in distress and vomiting. We immediatley called a code. This pt died. I am very depressed because this happened very fast and when he did show signs of worsining condition, it was too late. I feel has though this could be my fault and loose my license. Later during the shift another nurse found a kub result showing that the pt had a mild ileus. At this hospital, the results are always called in. Evidently the results was called in to the night nurse and she did not report. The doctor or I had not seen the result. I have been very depressed and discouraged wanting to quit nursing after this. I feel like a victim. I have convinced my self that there is no way the family is not going to sue. I have not heard anything or received a letter yet but I can't live my life wondering. I have worked so hard for my career and it seems as though I have failed. Is this my fault!!!!!

:o

Pt's vital signs were off for 4 days? I would think that within that time someone had alerted the doc,charted it and the doc has responded in some way ? An ilieus is not gonna kill ya unless they perf or dehydrate and lytes go off the chart. You have to wonder here what labs where done and the results. You nor the night nurse are at fault unless something is not being said. A called in report to the doc for an ilieus would have gotton an npo order, repeat kub,iv fluid change etc,,, bet ya something else went wrong. Do not wait for the grim reaper, I doubt he will come, worse u will get called into make a statement. This guy was bleeding,he ruptured or lytes were so way off he coded. Let us know,I am sure u will be ok,,,,good luck!

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Pt's vital signs were off for 4 days? I would think that within that time someone had alerted the doc,charted it and the doc has responded in some way ? An ilieus is not gonna kill ya unless they perf or dehydrate and lytes go off the chart. You have to wonder here what labs where done and the results. You nor the night nurse are at fault unless something is not being said. A called in report to the doc for an ilieus would have gotton an npo order, repeat kub,iv fluid change etc,,, bet ya something else went wrong. Do not wait for the grim reaper, I doubt he will come, worse u will get called into make a statement. This guy was bleeding,he ruptured or lytes were so way off he coded. Let us know,I am sure u will be ok,,,,good luck!
Good post. While it's normal to second-guess yourself when bad things happen, I think it's crucial for risk management to dissect this situation. Obviously, the ball was dropped by many people over several days. It's not a matter of who is at fault, it's a matter of determining what went wrong and where, then putting measures in place to ensure it doesn't happen again.
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It sounds like there was a lot of things that went wrong here. There may or may not have been something you could have done. We weren't there so we only have your recollection of the incident. This kind of tragedy of errors happens on a daily basis in hospitals around the world. Some patients die and some patients don't. Sometimes the errors contributed to the patients death, other times there is nothing that could have been done to save that patient. You WILL face these type of issues again some time in the future if you remain in nursing. All nurses question their judgement and actions at some point. As long as you have done all that you could with the information you had, then you did your job. And if you are ready to run from nursing the first time that something turns out adversely, you are going to be miserable unless you learn to handle your fears. We hold people's lives in our hands every day. Some days are great and other days suck. The choice is yours how you react to these situations.

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