Sentinel Events

[NYCHikerRN]

Hello everyone,

I'm a brand new RN. , just passed my NCLEX last week. :)

I have been volunteering at my local hospital as a "patient care companion" since February of this year, just to get that extra experience outside of my clinical curriculum and to increase my marketability as a new grad RN coming on to the workforce. As a companion, I often do 1-to-1's with acutely confused patients who are major fall risks (although, RN's are NOT supposed to assign volunteers to do 1-to-1... however, this occurs very regularly). Today, I had a patient unlike any that I had to deal with as both a volunteer or as a student nurse.

The patient was a middle-aged alcoholic who was admitted in DT's. He was completely delirious, and only oriented to himself. Alcoholics, as many of you know, get very aggressive and agitated in withdrawal. I was assigned to him as a 1-to-1.

All through the day, this highly tolerant gentleman kept trying to get up despite respectable doses of librium and PRN ativan. I haven't been volunteering for a few weeks, so I felt a little timid today, especially with such a patient.

The patient kept getting up, and instead of using an effective amount of force to hold him down and keep him in bed, I was simply following him and redirecting him, asking him to please get back into bed. His gait was extremely unsteady, and in multiple instances I had to prop him back up into alignment so he wouldnt drop down.

In this middle of this day, He aggressively got up and said he had to go somewhere, in his hallucinatory state. I tried redirecting him, but he shoved me aside and marched forward. I was asking the nurse for help as he walked forward. Next thing you know, he was on his hands and knees on the floor.

An incident report was filed. I felt like I should have known better, as a new graduate RN whose sole purpose in life should be the safety of the patient, no matter how many times they tell you to go ".... yourself". It made me question myself and my abilities. I knew what I should have done differently (be more aggressive in demanding he stay in bed), but at the same time I couldn't help but feel that the responsible nurse should have followed a hospital algorithm and put this extremely volatile patient on, at least, 2-point restraints or heavier chemical sedation.

Eventually, a high-level nurse came to interview the responsible RN on the details of the incident. I overheard her say something about "penalizing" someone. I'm not sure if she was referring to me, but I feel like she was (the RN downplayed it and said I wouldn't get in trouble). My stomach churned. At this moment, I felt like these 110 hours of volunteering would go down the drain as I would get terminated. In addition, I felt incompetent and felt like my job or license would be so vulnerable to termination if this had happened to me as a new hire RN.

So what do you guys think? Am I justified in feeling the way I do? Does this happen all the time and is it "no big deal" for the sake of your job security (so long as it doesnt happen in a consitent pattern)? I know falls are HUUUUGE things for hospitals, and they can get in trouble and lose JCAHO money and general prestige. It's really eating me up inside...

Please share your thoughts and advice. Thank you.

[dudette10, MSN, RN]

Why the hell is a volunteer doing a 1:1 at all, but especially on an active ETOH withdrawal?! If it happens all the time against policy, the culture of the unit or the entire hospital is to be blamed just as much as the nurse in charge of that patient.

During volunteer orientation, wasn't there some sort of policy about what volunteers can and cannot do? Ours can answer call bells and direct requests to the nurse, fetch water, do secretarial duties, etc., but they can't even touch a patient in a medical/nursing capacity.

[ChristineN, BSN, RN]

Take a deep breath. What happened was not your fault. A volunteer should never have been assigned to sit with such a pt. Most volunteers have no medical training, and the fact that you do is not something that they should be taking advantage of. I would have a chat with the head of volunteer services about how you are being asked to do things outside your scope of a volunteer.

[NYCHikerRN]

Dudette,

I don't recall them explicitly mentioning that volunteers are not to do 1-to-1's. Of course, warned us that even if we are SN's, GN's, or RN's, we are NOT allowed to practice any sort of invasive procedures or administer medications under volunteer duties. This was common sense to me. However, given how commonplace 1-to-1 volunteers are, I figured nobody really cared. And it's true, nobody really does care. It is just brought up as a technicality when something wrong happens. The RN responsible for the patient only then is reminded and possibly admonished.

ChristineN,

Thank you for the reassurance. I will definitely speak to somebody about it in the volunteer office. However, truth be told, I DO like doing 1-to-1's, as they are excellent learning opportunities for my future practice. It's just that I'm kicking myself in the butt because I should have known better, and I feel so much more mortal and at risk for termination, had this happened under my own care (for instance, if I didn't know how to deal with my ETOH patient). However, if I was in charge of care, I would definitely have sought out the physician and explained to him that the tranquilizers aren't effective, in hopes of modifying the plan of care.

I just feel very vulnerable is what I'm saying. I really don't want to lose my license, ever. Gah...

[dudette10, MSN, RN]

I'm just flabbergasted that it's commonplace for volunteers to do 1:1s. Patient safety is at stake here, and that is not something that can or should be delegated to a volunteer. It's against the Nurse Practice Act for goodness' sake. I wonder if it's also against regulations.

I do not feel that you will or should get into trouble for this. However, if I were you, I wouldn't accept 1:1 assignments again unless you become a paid sitter.

[Oh'Ello, BSN, RN]

I agree with Dudette10.

1. Falls aren't really sentinel events. Falls happen, people fall. Not trying to downplay it because falls are not something to be taken lightly... but he was in DT's... his mental status was not being addressed properly, he fell. With your very limited (if even existent) scope of practice as a volunteer.... his falling is NOT your fault.

2. Again... in accord with Dudette, Where I live (I'm not sure if its the same everywhere), nurses cannot delegate a damned thing to a volunteer. I know that you are also a new nurse (As am I, congrats, hooray!) but don't allow your experiences in clinical drive you down the road of role confusion in your volunteer work. If you're in the hospital as a volunteer and "companion"... then you are there to provide companionship, not redirection, report, restraint or whatever.

[nurseprnRN, BSN, RN]

If you are an RN, you are held to RN standard of practice wherever you are. What that means is that you can take a job (volunteer or otherwise) that explicitly states you can't give meds, etc.,and so you don't give them, but you are still held by the BoN to know what a reasonably prudent RN would do in a situation like this because you ARE an RN (if you weren't when this occurred, thank your lucky stars).

You knew that you should have stayed with him and called for help, but you left him alone while you went for help, and that's when he fell. I agree that the facility is negligent in assigning volunteers as sitters for people in acute withdrawal or who are serious fall risks. That means they should stop doing it.

You, on the other hand, should be aware of your licensure status and what that means no matter where you are. What if you had engaged with a drunk at the local Piggly-Wiggly, knew he was unstable on his feet, helped him for a minute, and then left him reeling in the vegetable aisle, and he fell and cracked his head on a cooler? You could be held liable for his fall because you knew he was incapacitated and you left him alone. If you had never approached him in the first place, or didn't even see him, you wouldn't be liable. But once you assume that connection (as with your volunteer job, too) you are held to RN standard, which means you don't leave an emergency situation until relieved by someone more competent.

[dudette10, MSN, RN]

You, on the other hand, should be aware of your licensure status and what that means no matter where you are. What if you had engaged with a drunk at the local Piggly-Wiggly, knew he was unstable on his feet, helped him for a minute, and then left him reeling in the vegetable aisle, and he fell and cracked his head on a cooler? You could be held liable for his fall because you knew he was incapacitated and you left him alone. If you had never approached him in the first place, or didn't even see him, you wouldn't be liable. But once you assume that connection (as with your volunteer job, too) you are held to RN standard, which means you don't leave an emergency situation until relieved by someone more competent.

You do legal nursing, correct? This whole paragraph leaves me reeling, and something about the hypothetical situation you describe and consequences make no sense to me. (Not directed at you, but at the expectations of an RN.)

Why would I be liable for a drunk falling and getting injured if I had previously tried to help then left him? Where's the statute, regulation, or case law that would allow that drunk to successfully sue me? What really doesn't make sense is if I know he's in trouble, but I choose to not intervene, I'm free and clear?

People talk about the "RN standard" all the time, but nothing is said in my Nurse Practice Act about it. Where does it come from? It has to be case law.

[toomuchbaloney]

If you are an RN, you are held to RN standard of practice wherever you are. What that means is that you can take a job (volunteer or otherwise) that explicitly states you can't give meds, etc.,and so you don't give them, but you are still held by the BoN to know what a reasonably prudent RN would do in a situation like this because you ARE an RN (if you weren't when this occurred, thank your lucky stars).

You knew that you should have stayed with him and called for help, but you left him alone while you went for help, and that's when he fell. I agree that the facility is negligent in assigning volunteers as sitters for people in acute withdrawal or who are serious fall risks. That means they should stop doing it.

You, on the other hand, should be aware of your licensure status and what that means no matter where you are. What if you had engaged with a drunk at the local Piggly-Wiggly, knew he was unstable on his feet, helped him for a minute, and then left him reeling in the vegetable aisle, and he fell and cracked his head on a cooler? You could be held liable for his fall because you knew he was incapacitated and you left him alone. If you had never approached him in the first place, or didn't even see him, you wouldn't be liable. But once you assume that connection (as with your volunteer job, too) you are held to RN standard, which means you don't leave an emergency situation until relieved by someone more competent.

How does an unstable drunk in a public place = emergency situation?

[NYCHikerRN]

You do legal nursing, correct? This whole paragraph leaves me reeling, and something about the hypothetical situation you describe and consequences make no sense to me. (Not directed at you, but at the expectations of an RN.)

Why would I be liable for a drunk falling and getting injured if I had previously tried to help then left him? Where's the statute, regulation, or case law that would allow that drunk to successfully sue me? What really doesn't make sense is if I know he's in trouble, but I choose to not intervene, I'm free and clear?

People talk about the "RN standard" all the time, but nothing is said in my Nurse Practice Act about it. Where does it come from? It has to be case law.

I never left him alone. He shoved me and marched forward as I was calling out for help in the hallway. I didn't explicitly leave him. He was steps away from me. I was overpowered...

[dudette10, MSN, RN]

I just did some googling. In my state, the applicable wording is in the Good Samaritan law. Nurses are exempt from civil liability unless an act or omission constitutes "willful or wanton misconduct." What's even more interesting is that this applies in public emergency situations as a Good Samaritan AND when performing nursing duties without compensation.

i did not further research the legal definition of "willful or wanton misconduct."

[toomuchbaloney]

Wilful and Wanton Conduct Law & Legal Definition

...exhibiting a reckless disregard for the safety of others,

acting consciously in disregard of or acting with a reckless indifference to the consequences, when the Defendant is aware of her conduct and is also aware, from her knowledge of existing circumstances and conditions, that her conduct would probably result in injury

A course of action which shows actual or deliberate intention to harm or which, if not intentional, shows an utter indifference to or conscious disregard of a person's own safety and the safety of others