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?

[Loo17]

Sounds like a series of little problems lead to a big problem. I work in the ED so I imagining the scenario went down something like this, day nurse had patient, labs sent. They weren't anticipating blood levels to be quite so low so a type and screen wasn't initially ordered. H&H came back low, ED MD decided patient needed blood and to be admitted. They print a consent, have the patient sign it, and maybe even put the order in to transfuse / units. They forgot to order the type and cross match or figured the admitting docs would do it. The order to transfuse is in, problem is the blood bank will never process the units or mention to anyone that the crossmatch was never done unless they are asked. At quick glance of the computer it appears everything has been ordered and we are just waiting on the blood type.

The day nurse saw the patient was getting admitted and was busy with ED patients, didn't have time to check the orders or figured the patient would be going upstairs soon and the floor nurse would do it. Maybe they even saw the order to transfuse but didn't notice the crossmatch was never ordered. Maybe they planned on following up with the lab in an hour to check on results but got busy and before they knew it shift was over and the patient was admitted.

3-7pm is one of the the busiest times in the ED. The day nurse reported off to the next nurse that the patient was admitted and just needed to be transported (I worked the floors and can say report in the ED is not as thorough as the floors, it doesnt always need to be).

Report on a stable patient (especially one that is going to the floor right away) might be as simple as patient from SNF baseline dementia, alert, pleasant, poor historian, h&h low, vitals stable, 2 IV's, Pt admitted for monitoring/transfusion all set to go to the flood once a transporter is available. Followed by "thank you so much for bringing them up so I can go home!"

Sure if the nurse coming on shift was not busy it would have been great of her to look over the orders and notice the crossmatch was never done. She could have then paged the inpatient admitting doctor and asked for the order. ED docs wont always write orders for patients that have been admitted and at least where I work a nurse cant just call the lab and ask them to do a cross match, a doctor needs to place the order. Chances are though at the time of shift change the nurse had patients new patients filling her rooms, assessments to do, meds to give, lines to start, etc. plus transporting your patient since the day nurse left without doing it. I am not trying to make excuses or anything but I can see how an order not being put in might be easy to miss. That doesn't make it right and I definitely think writing it up was the right thing to do but I am not really sure you can point the blame at any one person. It sounds like a system problem that needs to be fixed.

[kayern]

The scenario you describe is not new! Unfortunately, M/S nurses spend a lot of time completing tasks, infusions, admissions, etc from the ED. I know in my institution, the ED nurses cringe when I take report from them because I expect true SBAR HOC and question open orders, transfusions, etc. thanks to the EMR. They don't always take heed and complete the necessary open items when giving report from my staff, but when they give to me things are different. I consistently ask their manager, why that is the case and get a variety of responses. Many times, report comes from another M/S float nurse who is totally overwhelmed.

With take being said, I empower my nurses to take HOC the same way I do and ask the questions because once they assume responsibility for that patient (s) every outstanding issue is now theirs. Again, thanks to the EMR, we can support our questions and see exactly how busy the ER is, things are changing but slowly.

ER nurses are good in emergencies, but I challenge them to take the patient assignment a M/S nurse manages and see how an transfer from the ER with open orders, transfusions, medications can totally jam up the floor nurse.