Published Aug 27, 2004
i heard that there is a website where you can view sentinel events. they dont name hospitals/pts, etc...but just what happened and what was done about it.
do any of you have sentinel event stories. we had 2 last year.
1. a pt who had left ama from the er - walked outside to wait on his ride. he had a seizure and fell hitting his head on the concrete. he died. he had come in that am because he had had a seizure the night before. he had ran out of his medicine and wanted a prescription for refills. he was aaox3 when he came in. he had gotten mad because we were doing the whole assessment, labwork thing and all he wanted was a prescription.
2. ill use nurse a and nurse b. at change of shift in the er, nurse a gave report to nurse b. she had 4pts. nurse a had told her that the pt in bed 4 needed to be checked in (he had just arrived by ambulance). she gave report on the other 3 pts and said that they were all fine and sleeping. after nurse b checked the pt in - she made her rounds on the other pts. pt in bed 7 was dead and had been for a long time. she had come in with chest pain and wasnt even put on a monitor. the curtains had been pulled and there was no family with her. nurse a had written a note on the pt right before shift change - but obviously hadnt checked on her . she hadnt started an int, drawn lab or anything. guess who got in trouble. nurse b. nurse a still works there and doesnt accept any responsibility.
does anybody else have sentinel event stories? i guess im interested because it is a nurses nightmare.
hey erslave, have you checked the jcaho website (jcaho.org)? they are the ones who are asking for organizations to report se.
barefootlady, ADN, RN
older male patient came in for hernia repair, midabdominal. Surgery supposedly when routine, patient returned to floor after 2 hr stay in RR with routine orders. VS taken as ordered, patient took ice chips late afternoon, then took clear liquid diet for PM meal. About an hour after eating, c/o nausea, medication given as ordered. Patient continued to complain, vomited about 50cc clear liguid, urine output was not picking up but was holding steady at about 40 cc hour, NSS IV was infusing at 100 hr. Dressing was intact to abdomen, no drainage noted, bowel sounds were sluggish to upper quads, minimal to lower abdomen. VS were steady. Abdomen was tender, appeared to be increasing slightly, nurse took measure and recorded it. When shift change came, she gave all findings to on coming RN and stated she just could not put her finger on what was happening but patient was not recovering as expected from routine procedure. On coming nurse stated she would call doctor is pain med with antiemetic was not effective. Patient did get some rest from meds given and no further episodes of vomiting were reported. Next morning, same nurse coming on found patient in terrible pain, abdomen was greatly extended, no bowel sounds heard, urine output was less than 15cc an hour. Dr called, no answer, service called, still no call from MD, hospitalist who had cleared patient medically for OR making rounds, nurse was frantically trying to get someone to look at patient, VS crashing, hospitalist was asked if he minded looking in on patient, he agreed after nurse explained that surgeon would not answer beep. Hospitalist took one look ordered emergency CT scan, and lab work. Patient was bleeding internally, seems something had been nicked during surgery. Supervisor and administrator on call notified of patients condition and MD not answering beep. Finally surgeon came into facility, rushed patient to OR after getting phone consent from wife, and patient died on table. First fingers of guilt were pointed at nursing staff, documentation was there to prove patient was showing signs of problem but actually stable until about 4AM. Nurse coming on started calling at 0645AM, hospitalist was seeing patient by 0830AM, surgeon did not come to facility until 1:00PM. No charges where filed against nurses, hospitalist, but surgeon was later found to be suffering from a brain tumor, was doing surgery while in pain and on medication, and admitted to some memory problems and fine hand movement problems. No lawsuit was filed by family, they were never given whole story. Surgeon had brain tumor removed and last anyone knew he was planning to return to OR on limited duty. For weeks after this happened nurses were repeatly warned not to take any procedure for granted and to double check all patient VS etc. Yeah right, where was the added staff to do the job? Why was the physician not disciplined by board? Facility? Great cover up.
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