What just happened?

oceanblue52 · Sep 21, 2016

Wow. I cannot believe this happened to you! Actually, I can a little; this happened to me when I was a CNA and I didn't get report at all on a patient and only realized 2 hours later that he was mine and I knew nothing about the person. The charge nurse didn't notice this? Don't know what else to say other than it's a very bizarre, disorganized system that allowed this to happen.

Nurse3000 · Sep 21, 2016

Wow. I cannot believe this happened to you! Actually, I can a little; this happened to me when I was a CNA and I didn't get report at all on a patient and only realized 2 hours later that he was mine and I knew nothing about the person. The charge nurse didn't notice this? Don't know what else to say other than it's a very bizarre, disorganized system that allowed this to happen.

No because he didn't have any drugs of addictions or injections due. He was diet controlled diabetic, so no BGL taken either (gulps). I'm so freaking lucky nothing happened to him. I am responsible for overlooking the patient on my list but for not getting a handover on them either or someone regular checking the sheet of paper I'm not used to seeing that I had them and firmly confirming I do indeed have them. I just wished that happened. 2 hours is not so bad. .. but a WHOLE shift with no attention whatsoever. ... that is just insane and I'm traumatised by this. ... I'm waiting for a call to come into to discuss. ... :confused: I don't take mistakes well... It feels like I'm dying inside which is not healthy nor productive. I wish I read it properly but I also wish the room numbers were verbalised (like other hospitals) i.e. "you will be taking room 5-9" and that a handover was given. .. do you think I'm solely responsible? I'm scared

versican · Sep 21, 2016

Forgive yourself sooner than later. The process needs fixed. It was an honest mistake which seems to have no ill-results (and I bet you won't do it again...so make it a learning-moment). Did a physician round? It takes a team to take care of patients -- nurses, aids, doctors, dietary, therapies, pharmacy, housekeeping, volunteers -- so the patient probably had folks coming in.

In my job, we get verbal handoff of each patient at bedside, so it's unlikely to miss someone. Whoever has a patient does not leave until they've given verbal handoff of each of their patients. The process of getting your patients may need to be addressed so this doesn't happen again...you did not do it on purpose. If you had bedside reporting for handoffs, this never would have happened.

I'm sorry this happened to you, but keep your chin up and see the learning moment -- not just learning moment for you, but for the floor as it needs a process improvement.

SierraMoon, ADN, BSN, RN · Sep 21, 2016

I have regular nightmares about this very scenario, both not seeing a patient all day and leaving without remembering to give report. I'm sorry this happened to you and glad the patient was okay.

This is definitely more a system failure than your personal failure.

Nurse3000 · Sep 21, 2016

Thanks for your support guys. Will reflect on it some more and forgive myself too! Hooley Dooley! :blackeye:

Lev, MSN, RN, NP · Sep 22, 2016

HA! I had a nightmare like that too!

Harveyslake · Sep 25, 2016

The bigger issue here is that the off going nurse could be charged with patient abandonment. The patient remains their responsibility until report is given and responsibility for care accepted by the on coming nurse. I would find out who had the patient during the previous shift and find out why they left without giving report,.....to anyone.

Ruby Vee, BSN · Sep 25, 2016

I'm 2nd year doing agency work.
I got my patient load this morning.
The team leader said you have say, rooms 38-41.
I said sorry, she said check the book.
I checked book and overlooked my name with room 37 too.
thought I just had 4 patients. to compound the problem did not get handover on room 37.
There is NOTHING written next to their name;
Didn't even look at one chart.
end of day thought I'd done a great job. And team leader says hand over 37. I genuinely said I didn't have them.
Pt was not seen all day. no PPI or mild pain killer given. no vital signs. no call bell pressed. no shower. Pt jovially chatting with friend inside room.
can't believe it...
am petrified of the ramifications. and lucky nothing happened to him. thoughts or advice?

We all make mistakes. What matters is what you do after you made the mistake. I'll bet you won't make that same mistake again!

Years ago, I was in charge of CCU. We had four step-down patients on our unit, but there were no beds in the step-down unit. Typical staffing in step-down was 4 patients. We got a nurse from the float pool, and all four step-down patients were assigned to him. The assignments were clearly written on the assignment sheet, on the white board in the nurse's station and the night nurse swore she had given report on all four patients to Greg. He swore he only got report on three of them, and one of them was ignored for 12 hours. As the charge, I posted rhythm strips for the float nurse and answered the call light a few times, but the error wasn't discovered until near the end of the shift when I asked for updates on his assignment. I've had nightmares about that situation every now and again for the last 30 years.

You're responsible for what is written on the staffing sheet, not for what the charge nurse tells you. If there's a discrepancy, talk to the charge. She may have been answering a questions about room 37 while she was writing in your assignment and the written assignment may have been in error. Make sure that your understanding of your assignment agrees with the written sheet, even if you have to have the charge change the written sheet. Those sheets are kept for something like 7 years so if there is a problem down the road, risk management can easily identify who had which patient and which nurse had the patient next to him and might have covered for breaks, etc.

You understand the mistake you made and how serious the ramifications could have been. Now figure out how it happened and how not to let it happen again. Then forgive yourself and move on. That last is the most difficult part of the whole process.