Time to vent - my apologies in advance.

[Levitas]

Okay, let me begin by stating that I do not like to complain about my assignment at work. I just don't. I feel like we're here to help people, and my preference of patient should never determine my attitude while taking care of people who need me.

That being said, I had an interesting night at work the other day. (Sorry for the long rant.)

I've observed that a number of my co-workers aren't keen to the idea of having a patient who needs blood transfused. I get it, it can be time consuming. In the ICU, where you might have 2-3 patients, it's almost more manageable than on the Med/Surg floor where you've anywhere from 4-8 patients.

Myself? I actually don't mind transfusing, at all. But there are certain... things that absolutely irk me, and here's one of them...

I get into work, told by the day nurse that I'm getting an immediate admission from the ED, and that the patient will need 2 units PRBC's, no problem, really. This patient had a hemoglobin of 5.2, mildly symptomatic in the ED, mind you.

The patient hits the floor about 20 minutes into shift. No blood band on the patient, no problem, I proceed to complete my admission otherwise, and decide to pass meds to all other patients until Lab is finished cross/matching their blood.

An hour and a half goes by... I call down to Lab, just to check on the status.

"I don't see any order for a cross/match." Lab says.

You have got to be kidding me... This patient had been in the ED since Noon that day. Her labs were completed, and reported to the ED by 1430 that afternoon... The patient hit my floor at 1950. 5 hours...

5 hours without anyone, Doctor, Nurse, anyone making mention to the Lab that we needed a cross/match. It's one thing if the ED was swamped, and couldn't get the blood started, I can understand that, but to not even pick up the phone, and get the cross/match?? Seriously?

I immediately call the ED, and the nurse who brought the patient up tells me, "I didn't really get report on the pt., I was asked by the day nurse to transfer the patient up.

I asked, "Were you aware that this patient has a Hgb of 5.2?"

They state, "Day nurse told me it was low, but I didn't know how low."

Me, "May I speak with the nurse who had the patient?"

ED, "They're gone for the day. The doctor too."

Sigh.

I call the attending, and get the order myself. Call down to the Lab, and ask if they can get this one done, stat, due to how long the patient has already been waiting. Fortunately, they did. However, the patient's blood had antibodies.... Ergh.

The blood wasn't available until 0330, and they were febrile, so I had to wait another hour (post acetaminophen) before starting transfusing at 0500. What a mess.

And I can see how this would have ended, especially if the patient continued to be symptomatic. The cross-hairs would have been on my forehead... Nuh uh, ain't happenin'. I absolutely hate doing it, but I reported this incident. To the supervisor, the clinical leader (on my floor, and the ED), as I refuse to be bait for someone else' negligence.

Had I been the one on the phone to get the report (remember, the day nurse had already gotten report, and just handed it off to me when I came in), I would have resolved this before the patient hit the floor. But it was a cascade of mishaps, just waiting for me when I walked into the door.

The cherry on top? I ended up with another admission at 0530, almost at end of shift, and that patient came up with an infiltrated IV, haha (I laughed at the time too).

Really though, you guys don't think I was in the wrong for being upset, do you? Or that I reported the incident? I mean, that patient could have been seriously injured due to this oversight. I've got to protect myself as much as the patient, yes?

[__nurse_t]

Levitas,

hey I was reading some of your posts on another thread about Lutheran school of nursing from where you graduated from is there anyway you can email me directly as I have a couple of questions? My email is [email protected]. It would be greatly appreciated! Thx

[Levitas, BSN, RN]

Thanks for the responses, guys :)

Foremost, I am definitely not bashing the ED (nor did anyone say that I was, but I'm just putting it out there). I love my ED nurses! I love EVERYONE at my work. My ED nurses are always reliable (at least at night), they come help me whenever I need it, don't shy from my questions, and are great to work with.

Second, the symptoms she was exhibiting in the ED (from the 2nd handed report I got) was that the patient was experiencing acute pain (flank, back, generalized), and though no one told me her saturations, she came up with O2. (Also noted in report that the patient was mildly symptomatic, but aside of the obvious pain, and deduction of low saturation, due to the presence of nasal cannula, and verbal report from the patient, I wasn't given any specifics.)

To clarify, the order was written (after re-reading my post, I noticed that I omitted that, my apologies), but not in the chart, and it wasn't correctly written in the computer. The Doc wrote it as a miscellaneous order, and the lab apparently was never notified of the need of a cross/match.

At my hospital, 5.2 is a critical low, and the lab person whom I spoke with stated that they did indeed call it into the ED. That should have prompted immediate action, in my opinion. Somewhere along the line, the communication got severed, and it turned into something completely obtuse.

Also to note: Most of the time, (every other instance aside of this one), ED does start transfusing before bringing the patient up. Honestly, after I got over my initial shock/anger of the situation, I was more curious than upset. I wanted (still do) to know what happened. I want to know, so that in the future, if a similar situation is going on down there, I can prepare myself to ensure that the patient has everything they need to get well.

This is in no way a thread to incite an "Us vs. Them" mentality. I love everyone, but even the strongest need a moment to vent at times :)

[That Guy, BSN, RN, EMT-B]

Things do get dropped from time to time unfortunately. That doc should have never placed that as a miscellaneous order. It doesn't go to lab, Blood bank, nothing like that. Also one of the things I like doing the LEAST is calling report up on a pt that has been there for 6 hours. I feel like I know nothing about them. Sure I get handed report but that doesn't include everything, so it does suck. Hope the pt is doing well and good catch on your end.

[KelRN215, BSN, RN]

An incident report was definitely warranted... systems error, they need to find a better way. Hgb of 5.2 would be a critical value- lab calls with results, RN pages MD, action required within 30 minutes (45, 60, whatever is your policy). That didn't happen so follow-up is necessary.

[greenerpastures]

Then come on down and spend a few days with us and see that people with PE can have clear lung sounds.

In patients with recognized pulmonary embolism, the incidence of physical signs has been reported as follows:

• Tachypnea (respiratory rate >16/min) - 96%
  
• Rales - 58%
  
• Accentuated second heart sound - 53%
  
• Tachycardia (heart rate >100/min) - 44%
  
• Fever (temperature >37.8°C) - 43%
  
• Diaphoresis - 36%
  
• S3 or S4 gallop - 34%
  
• Clinical signs and symptoms suggesting thrombophlebitis - 32%
  
• Lower extremity edema - 24%
  
• Cardiac murmur - 23%
  
• Cyanosis - 19%
  
  
  Not only that, but it is weird to me with that low of a Hgb, pt being symptomatic, that they weren't transfused in the ED. We can do it MUCH faster than you guys can ( not a dig on you guys at all just how we are allowed to do things ). I would report it to to hopefully help find a flaw in what was going on. Who knows, maybe the admitting doc said to just get them to the floor.
  

I agree with the statement that the ED can get blood in much faster, which helps the patient in the end. In our facility there is a "soft guideline" that anything transfused in 2 hours or less is considered an emergent rapid infusion which can only be done in the ER or ICU. If the ER can get that blood in faster with that Hgb, it's much better for the patient. Our floor manager WANTS all our patients to be over 3 hours per infusion - so if you've got 2 or 3 units to put in, it's an all night process.

For the OP - report it I say! I've done it before. The floor manager complained that " nurses shouldn't be telling on other nurses"; I promptly told her "A patient could have had serious complications because of this delay, I'd do it again." PCM didn't really like my answer, but people seem to be paying attention a little bit more to getting blood started sooner.

[TriciaJ, RN]

It shocks me that people still have the mentality that incident reports are like "telling on" someone. We're not kids in a playground. How else do we identify the factors that get in the way of patient safety or timely care? Most hospitals have long since promoted a non-punitive culture of completing incident reports. It should be considered an essential part of Continuous Quality Improvement (there's surely another buzzword for this by now).

You were absolutely right to report this. One very good reason is CYA. The other good reason is responsibility to your employer, coworkers, and patients. How many of us are alive today because someone like you caught something and followed through?

[tokmom, BSN, RN]

It shocks me that people still have the mentality that incident reports are like "telling on" someone. We're not kids in a playground. How else do we identify the factors that get in the way of patient safety or timely care? Most hospitals have long since promoted a non-punitive culture of completing incident reports. It should be considered an essential part of Continuous Quality Improvement (there's surely another buzzword for this by now).

You were absolutely right to report this. One very good reason is CYA. The other good reason is responsibility to your employer, coworkers, and patients. How many of us are alive today because someone like you caught something and followed through?

And you can bet your bottom dollar this wasn't the first time this happened. The M.D.meds needs to be trained on placing orders.

[SHGR, MSN, RN, CNS]

It shocks me that people still have the mentality that incident reports are like "telling on" someone.

Right, it's 2014...time for modern, systems thinking. This kind of manager is stuck in what, the 90's? Do they wear a blouse with a big bow at the neck to work, and momjeans at home?

Most hospitals have long since promoted a non-punitive culture of completing incident reports. It should be considered an essential part of Continuous Quality Improvement (there's surely another buzzword for this by now).

You are right- it IS an essential part of QI.

[skylark, BSN, RN]

Personally, I would have called the lab as soon as I received the pt,as a courtesy, to make sure they knew where the pt had moved to, and who to call regarding the transfusion.

Doesn't change the confusion at the ER end, but at least it would have been recognized much earlier that there was a problem.

[Julie Reyes, DNP, RN]

The blood thing - definite need to report that! You did the right thing.

Infiltrated iv - that could have happened on the way up - unless you noticed that there was edema. I have had several incidents where the IV was kicked and infiltrated during a transfer (ok, I have a lot of babies that kick their saph and can blow iv's easily - even when they are protected better than Ft. Knox!). I never jump to conclusions on that. Kids are a lot different from adults though - and I have never worked in an adult hospital, so I have no knowlege of how that would work out...likewise, i wouldn't think an adult would scramble around in a bed like toddlers do either! I could be wrong though! haha!

That patient was lucky you were his nurse - way to be an advocate!

[tokmom, BSN, RN]

The blood thing - definite need to report that! You did the right thing.

Infiltrated iv - that could have happened on the way up - unless you noticed that there was edema. I have had several incidents where the IV was kicked and infiltrated during a transfer (ok, I have a lot of babies that kick their saph and can blow iv's easily - even when they are protected better than Ft. Knox!). I never jump to conclusions on that. Kids are a lot different from adults though - and I have never worked in an adult hospital, so I have no knowlege of how that would work out...likewise, i wouldn't think an adult would scramble around in a bed like toddlers do either! I could be wrong though! haha!

That patient was lucky you were his nurse - way to be an advocate!

Depends on the patient! Some are very wiggly and go after that IV as fast as you can say geriatrics!

[brandy1017, ASN, RN]

So typical of my ER. You get report from a nurse that hasn't had the patient. When there is an issue that something she be done, the answer is the Dr didn't order it. I don't understand that! I think it is part of the nurses job to be proactive and speak up if something should be done that the Dr didn't order, but all the ER nurses give me back the same response, the Dr didn't order it. Like they don't have a mind to think for themselves. What is the problem! Is it laziness or some weird ER culture that a nurse can't speak. Anywhere else in the hospital nurses speak up and advocate for their patients, not ignore things because the Dr didn't order it! Looking forward to hearing what ER nurses have to say.