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.

[NYCHikerRN]

I don't recall the OP saying she was shoved away from this guy and that's when he fell. I was under the impression that she went to the door to call, moving away from him to do so, and that's when he fell. OP, if he pushed you away and then fell from the effort of pushing you, that's different. But if you moved away from him first (and is that what you mean by "explicitly leave him"? You were still in the room but you didn't say, "I'm leaving"? Not clear.) and then he pushed you and fell, you were wrong to do that.

This is what happened:

The patient again made an effort to get up. I told him to stay in bed and that he is at a high risk for falling due to his condition and the medications he recently took. He ignored me, got up aggressively, and marched from the hospital bed beside the window toward the door. Before he could get to the door, I blocked him with my body and he shoved me aside and continued walking. I yelled out for the nurse who was sitting at the mobile computer station a couple of doors away (not following him any longer). He went forward a few steps and ended up on his hands and knees by the doorway.

If I did something wrong by doing this, then I don't know what to tell you. I was NOT going to keep pursuing him until he flat-out punched me in the face (which is something I was fearing he would do at any time, given his violent social history).

[JustBeachyNurse, LPN]

This is what happened:

The patient again made an effort to get up. I told him to stay in bed and that he is at a high risk for falling due to his condition and the medications he recently took. He ignored me, got up aggressively, and marched from the hospital bed beside the window toward the door. Before he could get to the door, I blocked him with my body and he shoved me aside and continued walking. I yelled out for the nurse who was sitting at the mobile computer station a couple of doors away (not following him any longer). He went forward a few steps and ended up on his hands and knees by the doorway.

If I did something wrong by doing this, then I don't know what to tell you. I was NOT going to keep pursuing him until he flat-out punched me in the face (which is something I was fearing he would do at any time, given his violent social history).

IMHO the first wrong was giving a companion volunteer (who happened to also be a newly licensed RN ), any volunteer a 1:1 sitter assignment. These should only be assigned to paid personnel trained to do 1:1 monitoring and document the same. Some facilities use security officers others use CNAs. A companion volunteer is for the lonely patient that just needs a friend.

As far as your actions, physically blocking him was beyond the scope of a companion and possibly a sitter. The fact that he didn't directly fall as a result of you blocking him and him shoving you aside is partially relevant. You shouldn't have been put in the situation in the first place. Sometimes a 1;1 is a companion such as a fall risk Alzheimer's or dementia patient that can easily be redirected with conversation, diversion or even reality orientation. Such as " I need to get up, the roast is going to burn" " it's ok Mrs. Jones, you can rest, I already turned off the oven. Can you tell me which flowers you planted in your garden this season?"

[Anna S, RN]

This situation is in no way a Sentinel Event.

[NICURN29]

I just can't get past the fact that volunteers sit 1:1 assignments in this facility. The only people we have certified to do 1:1s are people who have been oriented to the task. It is about so much more than just baby-sitting a patient. If this were happening in my facility, I would not be okay with it.

[Been there,done that, ASN, RN]

STOP blaming yourself. You were thrown under a very large bus.

Patients experiencing DT's are the most volatile patients we come across.

The problem lies with the facilities half (moon) policies.

Get away from that facility. Lawyer up with your malpractice coverage if necessary.

It's NOT you.. it's them.

[icuRNmaggie, BSN, RN]

If he did not die or suffer a permanent disability ( for example, a head bleed, with permanent physical or cognitive impairment)

then this is not a sentinel event.

These people put you in harms way. As a volunteer you would not have even received workmens comp if you were injured.

Any alcohol detox pt with a CIWA score >20, like him is an automatic ICU transfer for a precedex gtt. You might want to re-think working at this place as they do not know what they are doing.

Stop worrying, you did nothing wrong.

The nurse who left you to your own devices with an agitated aggressive patient was totally negligent and she should be held responsible, not you.

[Nurse SMS, MSN, RN]

I too was wondering why on earth he wasn't being transferred to ICU for an Ativan drip. He was a very clear danger to himself and others and you were clearly at risk being in there with him. There s no way anyone could have prevented that fall.

[icuRNmaggie, BSN, RN]

If you continue to work as a patient safety aide or volunteer, you need to know how to call for help in the event of an emergency such as this.

Anyone can call a rapid response or whatever the code is for a violent out of control person. Never try to stop a violent patient by yourself. Sit near the doorway so that you can not be cornered in a room by a violent pt. Have a phone handy and know the emergency number.

Best wishes, Maggie