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Discussion

unsafe assignment? (long - sorry)

I'm a newer RN on a CCU unit. Been here for about 6 months now. I've got a good head on my shoulders, and have a decent, basic handle on things, and I'm also 8 months pregnant...

Here's the situation.... We are a smaller unit, and get a lot of ICU overflow. I went in last night and was assigned the 'usual' 3:1 ratio. One was a transfer out. and the other was an empty room for a new admit. Well - the new admit turned out to be a pt w/ scabies, so I wasn't allowed to take the assignment. The charge nurse flipped things around and I ended up with a heavy care ventilator pt with a TON of meds, femoral TLC, A-line and contact isolation for c.diff, and labile BP's, on vaso, propofol, and dobutamine. The second pt weighed 300+ lbs, had a newer chest tube, insulin drip with hourly glucometers, morphine gtt and hovering, needy family. And the 3rd was the same transfer out pt, who was ok - but psych and inappropriate, and also contact isolation for MRSA (worried about him getting out of bed)

I told the charge nurse I needed help - no ifs, ands or butts.... so she gave me an LPN to do the insulin checks from 9-11, (I still had to change the drip levels) I ran around like crazy from 7-11 just trying to get everything organized since the assignment changed, getting another report, etc. 11p came around and I lost the LPN, but got to hand off the transfer out pt.

Needless to say, I was back on the insulin drip, chest tube, and the ventilator pt. The vent pt coded around 2am. She was getting a breathing tx and the alarm was going off, I checked her, vitals great - just alarming d/t the tx. I went to break room to sit for the first time all night and eat. 5 min later she brady'd down and BP bottomed out..... She survived the code THANKFULLY..... But all night (prior to this)- I kept thinking - this is unsafe, etc. I let my charge nurse know,and she tried to help me as much as she could w/ the assingment....... but still - what do you do in this situation?

Another seasoned RN and I talked about it. and she told me, it had nothing to do with my care for this pt, it just happened. (she's poor prognosis) but I just can't stop thinking that running around like that - I'm personally unable to care for and watch these unit pts like I feel that they need to be watched.... I feel safer and have more peace of mind when I'm able to watch the monitors and notice those little changes, etc....

This isn't the only time this has happened on our unit. It does seem like we have 3:1 ratios quite a bit - especially with vent pts..... which I personally don't feel safe having 3 pts w/ a vent......

I don't know - what do you guys think? (sorry this was so long)

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Three critically ill patiwents is too many.

I suggest that you keep a diary.

When you get home from a shift write something. It could be the number of patients. If it is a good shift when you could give the care your patients need - write that.

If you don't get a break write that.

If you float, include that and the unit where you worked.

Any time you think it is unsafe tell a supervisor or manager then write what you said and who you told as soon as you get home.

In the unlikely event of a lawsuit or report against your license that diary could protect you.

An incident report is not evidence in court but your diary is.

Then if asked, "Why did you accept the unsafe assignment?" you can answer, "Because it would have been worse if I left. And I was afraid of being disciplined." (Or whatever is the truth)

Then if they claim, "We didn't know the nurse thought it was unsafe." your diary is your proof. Because you write it daily. And don't put in any HIPAA violations that can identify a patient.

If you are really brave and the other nurses on your unit agree you could write a letter documenting your concerns. Go up the chain of command.

Good luck to you!

Yuck! How did they think having an LPN do the accuchecks was going to help- especially since the pt had an A-line to draw from??? Sheesh! Personally, I would be more worried about having a 3rd patient in an insulin drip than with a vent. At least the vent will alarm if anything goes awry.

Sorry you had such a terrible night. I agree with Herring- you have to make sure you alert a supervisor of any unsafe staffing, and record it for yourself. I always carried a "this is seriously screwed up," notebook for stuff such as that. You'll at least have it recorded that you alerted someone who had the power to fix the problem. You may also want to check your state nurse's assn. website, and see if they have an Assignment Despite Objection Form. This is a form you can fill out, and then give a copy to the supervisor you notified, and fax one to the nurse's assn. This will help to CYA in the event this happens again (not that I think you should stand for this again). Here's an example from my state's nurse's association:

http://www.kentucky-nurses.org/AssignmentObjectionForm2003.htm

  • Author

Thankyou all for the advice - I am going to definately start a diary and document it all. During report I mentioned to the day shift RN that I wasn't comfortable w/ the assignment and he did mention to me about that Assignment despite objection form. I just looked at my board of nursing site, but could not find it. I'll keep looking though...

It's intimidating though.. I need to protect my license, but at the same time, I'm practically still a brand new RN and don't want to be 'that one' that starts trouble. The mgrs say I'm doing great and only have good things to say about me (new grad straight into critical care) but I'm also not gullible. I understand that if something were to happen, I'm on my own. This is tricky.... I guess I'm going to just document it and go from there?

The form may not be on the BON website- check your state nurse's association's website. Remember: the BON is there to protect patients, your state nurse's assn is there to protect you.

Also, if you continue to take more patients than the more experienced nurses on the floor, then they will expect you to keep doing it. You may have to refuse, or ask for the lowest acuity patients in the 3 group next time.

Good luck to you!

  • Author

Thanks again -

When I was talking with the more experienced RN, she mentioned that I might want to talk it over with our head nurse manager. Just to let her know the situation and that although I feel comfortable in the unit - I don't feel comfortable with those types of heavy assignments - for my safety and especially the patients. I think I might have to do that. I couldn't live with myself if something happened to a pt because of something that could have been avoided.

I'm one of those perfectionist type people - or at least - I feel more comfortable when I know exactly what is happening w/ my pt by the minute. vitals, etc. I don't feel comfortable 'waiting' for the monitor alarm to go off or vent alarms to beep. I like to be on top of those things and watch the monitors and patients first hand.

I know at my hosp., and is written in the Hosp. Nursing Policy and Procedures, that if you are pregnant you are NOT susposed to have any pt. on isolation(contact) precautions, while pregnant. Espically 2 pt's on contact precautions while pregnant! I am SOOO glad that the scabies pt. was re-assigned. Scabies, god I hate bugs (literal BUGS).

I know as nurses we probably have MRSA,VRE,ESBL, or what ever the new super-bug is, embedded in our systems no matter how much we scrub ourselves or bathe in germacide, and ETOH wipes. At some points I am ready to scrub my skin with Bleach and Ajax b/c I am so paranoid of these superbugs. Infact my aunt who is an ER nurse mananger in Philly told me that the Board of Health Swabbed the Pyxis and found MRSA ,and VRE on the keyboard and Med pockets of the Pyxis, OK GROSS, but that's the nature of the business I guess.

As far as you feling safe with you pt. load, I would def. take that up with either your Nurse Manager, Unit Director, or the Nursing Supervisor.

I would be more concerned with the fact that you are 8 months pregnant, and that you got an assignment that Involved 2 contact isolations and almost a 3rd one.

Remember you also have to worry about youself. I know it sounds selfish, and as a nurse we are there for the pt.'s but if you feel UNSAFE, esp. as a critical care nurse, you need to say something, and you are not going to 'start trouble' by doing so. If anything you are letting the Managers and Higher 'Ups' know how you feel.

I KNOW as a new nurse (I am 10 months, almost 11 months into my 1st year) you want to show that u can handle these situations, but sometimes no matter what we do we can't prevent this "stuff" from happening.

Keep a diary, I do, of all the "stuff", that happens on your floor. It helps you vent, and you also have a log of the problems that you deal with on a nightly basis. I was so angry about the "UNSAFE" feeling on my floor that I just showed the Unit Director of Nursing on my floor, all the "stuff" I have been dealing with on Night SHift (and I have been on nights for about 8 months),and I am FAR FAR FAR from a kiss *** but I am worried about my license. CYA, was one of the most imp. things I learned in NS other than your ABC's and I am going to carry it to the grave.

good luck sweetie!! ANd congrats on the pregnancy, enjoy your maternity leave!!!

Another thing to remember is that you can technically refuse an assignment. The hospital might not like it and come after you for it, but that is your right. 3 patient assignments can be very difficult and unfortunately it has become the norm in some units.

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