Sentinal event

Jules A, MSN · Feb 26, 2015

I am so sorry this happened. Shift change is when so many bad things can happen.

Hugs, Jules

cheezwizz90 · Feb 26, 2015

Missed signs? The "signs" can be very vague and subjective, if present at all. If the patient wanted to end her life, she would have done so no matter what you did to help her unless she was in a padded room with all extremities tied and a sitter beside the bed. Don't beat yourself up. I am sorry that this happened to you.

Trisaratops · Mar 2, 2015

How often do the techs do checks? On our adult units we have noted that most completed suicides happen around shift change in the afternoon. The room door are closed, groups are scheduled and we do q5 min checks.

I'm sorry this happened

Long Term Care Columnist / Guide · Mar 2, 2015

When I was IP, there were about 500 ways a patient could NOT hurt him/herself. But sure enough, a guy we called Manic Man managed to cut his wrists by using the jagged end of a toothbrush he'd snapped in half. So yes, if a person really, really wants to self-harm, they'll find a way to do it. And that can't necessarily be prevented, sad to say.

Davey Do · Mar 3, 2015

I, too, express my empathy with this situation, NursKris.

I have not dirctly experienced such a situation, but the Facility where I work has, having had a "Successful Suicide" occur during Shift Change.

Too often, Shift Change is a Chaotic Time of Information Exchange and Superfluous Socializing. Before it was Mandated, and having a history of being known as a "Hard A-- Wet Blanket", I made sure a Staff Member was always on the Floor with the Patients.

I remember the words of my first Nuring Instructor: "Always be there. If you can do nothing else, be there".

The Very Best to you, NursKris.

Jules A, MSN · Mar 3, 2015

I have to say I'm really surprised this thread has gotten so few comments. This is something we are all susceptible to and devote our careers to preventing. I would expect an atmosphere of supportive camaraderie from our fellow psych nurses especially in this universal situation.

NursKris, how are you and your team holding up?

NursKris · Mar 3, 2015

The PCAs make frequent rounds. This patient was not on q15minute checks nor were any of her roommates. But we do make rounds approx q15minutes anyway. This happened at 0645.

NursKris · Mar 3, 2015

I have to say I'm really surprised this thread has gotten so few comments. This is something we are all susceptible to and devote our careers to preventing. I would expect an atmosphere of supportive camaraderie from our fellow psych nurses especially in this universal situation.
NursKris, how are you and your team holding up?

We are doing well. Some new procedures in place. Just trying to keep everyone safe. Thanks for all the kind words.

Jewelsforme · Mar 5, 2015

Anything can happen, although we hope not. With the very best laid plans and with our eyes literally on the patient, there will be moments our eyes cannot be on the patient. And if we take a break perhaps the next person may not check as frequently as ordered or required. Patients are very intelligent and know when the best time is to attempt. If your dept is normally chaotic during change of shift, the patients will quickly observe that and plan. Fortunately this has not ever happened where I worked, when I worked. Perhaps more bodies could be performing observation while report is going on, even if those bodies are supervisors, secretaries, and floats from other depts. Eyes are eyes and patients have the right to get through the worst time of their lives with the safest place we can provide for them. However, if someone is intent on dying, along the lines of "as long as there is a will, there will be a way." We must do all we can to remove those "ways" until the patient is stabilized with the correct meds and therapies. Best wishes to you because this would be a heart breaking situation for all involved.

Laurel32 · Mar 10, 2015

I am new in psych (working as a tech while in nursing school). This post really hit home. We had a patient attempt suicide last weekend, fortunately he did not succeed. I've been verbally and physically assaulted, but this is the first time I almost cried. :hugs:

302queenpa · Mar 11, 2015

Sorry this has happened to you. Big Hugs. That being said we can all spend hours saying what if we did this or that it won't go any good sadly this person was set on ending their life and nothing any nurse or tech or doctor did would have changed that mindset sadly.