What is the worst mistake anyone has made?

[DR2004RN]

What is the worst mistake anyone has ever made? What happened to the patient? I am a new grad float pool RN who was working in ER last week. I was the only nurse working in our "overflow" area. That is where patients go when they are admitted, but no beds are available on the floors. I was taking care of three patients. That dosen't sound bad, but I had to do all of the admitting paperwork also. It's like having three admits all at once. Anyway I had a patient who was being admitted for exacerbation of his COPD. He was on Bi-Pap in the ER. Respiratory suggested I put him on a nonrebreather to transport upstairs because the Bi-Pap machine did not have a battery source so it would not travel. At 10pm my patient took his PO's and had sips of water. Shortly after, he got a room upstairs and I took him up on a nonrebreather. When I got him to the floor his sats were very low, (81-82%) so we ran around to get a flow meter so that we could get him back on the bi-pap. Of course the only flow meter available didn't work properly so we put him on the bi-pap and used the portable O2 source. I stayed with him until his sats climbed back into the 90's. I went out to the desk and told his nurse that his sats were back up but that the portable O2 tank did not have much left in it. I then went back downstairs to my patients in the ER. A short time later the Nursing Supervisor called me to say that I took an unresponsive patient upstairs, and just left him there. And that right then he was getting tubed and sent to MCCU. I told her just what happened. It was close to shift change at this time, so she did not investigate but instead let the Night Nursing supervisor deal with it. The Night NS, came to tell me that it was another nurse (not the nurse for the patient) that called to say I just left this man. Yet another nurse spoke up for me, to say that I did not just leave him, that I stayed up there with him for a while before I left him. And that I reported off to his nurse before I left the floor. Needless to say I was devastated!!! I was crying, and shaking. The NS told me not to worry about it, the patient was intubated in the MCCU and was hemodynamically stable, and would be just fine. She said that was "a typical COPDer" The rest of the shift was horrible (I worked until 3am.) Now, I am feeling very incompetent, and I do not want to go back to work. I am sure that other nurses feel that I should not be allowed to take care of patients. I feel horrible! I asked myself earlier in the night why this man was going to a regular floor when he needed a unit bed, but I did not act on my gut feeling. I told the Night NS this and she said I should always act on my gut. Basically she told me to get over it and move on. I asked her what would happen to me and she said nothing. I didn't do anything wrong. She also said she would be speaking to the other nurse who called the NS. Later she came back to speak to me and tell me that she spoke to the other nurse. She told me not to worry about it. Look at it as a learning experience, and that everyone has made mistakes. I am not so sure anyone had done anything this horrible though!

[ERNurse752, RN]

You totally did nothing wrong. You told the other nurse he needed to get off the portable O2, and she didn't do it. That's not up to you. You waited to make sure he was stable, then reported off to her. Your responsibility ends at that point.

He wasn't a "typical COPDer" in this case - she was negligent in not making sure he had sufficient O2. Otherwise, sounds like he was doing fine.

Did she say what was said to this other nurse? This is a pretty major mistake to have happen. But again, not your fault and no one should think any less of you as a nurse.

[CoffeeRTC, BSN, RN]

Was the pt stable when you left? Sounds like you gave report to his nurse before you left. She took responsibility of him them...not your fault. Pts go bad....esp COPDers.

[DR2004RN]

I didn't ask because she just kept telling me not to worry about it.

You totally did nothing wrong. You told the other nurse he needed to get off the portable O2, and she didn't do it. That's not up to you. You waited to make sure he was stable, then reported off to her. Your responsibility ends at that point.

He wasn't a "typical COPDer" in this case - she was negligent in not making sure he had sufficient O2. Otherwise, sounds like he was doing fine.

Did she say what was said to this other nurse? This is a pretty major mistake to have happen. But again, not your fault and no one should think any less of you as a nurse.

[DR2004RN]

The patient was awake and could answer some yes/no questions with some difficulty though. His breathing was labored but he had been breathing that way all evening.

Was the pt stable when you left? Sounds like you gave report to his nurse before you left. She took responsibility of him them...not your fault. Pts go bad....esp COPDers.

[UM Review RN, ASN, RN]

I stayed with him until his sats climbed back into the 90's. I went out to the desk and told his nurse that his sats were back up but that the portable O2 tank did not have much left in it. I then went back downstairs to my patients in the ER. A short time later the Nursing Supervisor called me to say that I took an unresponsive patient upstairs, and just left him there. And that right then he was getting tubed and sent to MCCU. I told her just what happened. It was close to shift change at this time, so she did not investigate but instead let the Night Nursing supervisor deal with it. The Night NS, came to tell me that it was another nurse (not the nurse for the patient) that called to say I just left this man. Yet another nurse spoke up for me, to say that I did not just leave him, that I stayed up there with him for a while before I left him. And that I reported off to his nurse before I left the floor.

OK, let me get this straight. You got the patient to the bed, made sure he was satting ok, and gave nurse-to-nurse report. When you left the patient, he was not unresponsive.

Now to fill in the blank: Sounds like that nurse carried on with another patient. A THIRD nurse passing the room saw the patient in respiratory distress and made UNTRUE ASSUMPTIONS.

Over the course of the next few hours, everyone got the story straight. You did NOT abandon the patient. You did NOT fail to give report. You did NOT fail this patient in any way. The nurse you reported to should've gotten him an O2 tank. And it woud've been nice if the Respiratory Therapist accompanied his transfer since the patient really should've been on the bipap, but that's not always possible and you did nothing wrong.

Therefore, please stop beating yourself up about it, ok?

You've already thought of a couple of ways to improve the next time even though you didn't make a mistake. You can be my nurse any day.

[DR2004RN]

Looking back though, he had been struggling to breathe all evening, but was able to speak more early on. I guess I should have picked up on this change. That he was speaking coherently early in the shift but later was only able to answer yes/no questions. I did think though, that he was exhausted from working so hard to breathe. This is why I feel incompetent and like this was all my fault.

[TennRN2004]

As someone else said, these type of COPD patients who come in needing Bipap can go bad very quickly. From what I'm seeing of the situation, you did nothing wrong. Actually, I would say you did more than most ER nurses who are rushed to get back by staying with the patient until the sats came up. No offense to ER nurses, but you know when they bring you a patient as the recieving nurse, it is your job to get in that room, assume care of the patient and let them get back to the ER. It's not your fault that nurse didn't come in the room when the patient rolled in the room.

Bottom line in my hospital, we'll try a labored COPDer on bipap first, hoping to not have to intubate them, but sometimes you do intubate no matter what. I think from what you've described, this patient may have been one who got intubated regardless of what happened. If he was labored and only able to answer yes/no questions, the pressure of the bipap is probably not gonna be enough to carry him through. One question though, I'm assuming respiratory got some gases on him. What did those look like? We usually get an ABG when they come in, they get one an hour or two after on bipap to see if the bipap is effective.

If you got the ABG results after he had been on Bipap for sometime, and they were not really improving, then maybe you could've went to the doc with those and asked about the patient getting a unit bed, based on his ABGs, respirations continuing to be labored, decreasing ability to exert himself even answering questions, etc. That way, you have something to go along with your instinct that he's not a stable floor patient.

I woudn't give it another thought, except be more careful when I transfer patients to that floor to yell so everyone can hear me "the new patient is responsive, I'm leaving now" :rotfl: I think you did a great job, just remember your confidence in your nursing skills is very important. Don't let another nurse make you doubt yourself when you know in your heart you did the right thing by your patient.

[DR2004RN]

I have to admit I did not look at his gasses. Any labs that were drawn were done before I came on. I did not look at his labs. Although I should have. I usually do look at labs on my patients but I did not get to do that in this case. It is something you bet I will do the next time though!

As someone else said, these type of COPD patients who come in needing Bipap can go bad very quickly. From what I'm seeing of the situation, you did nothing wrong. Actually, I would say you did more than most ER nurses who are rushed to get back by staying with the patient until the sats came up. No offense to ER nurses, but you know when they bring you a patient as the recieving nurse, it is your job to get in that room, assume care of the patient and let them get back to the ER. It's not your fault that nurse didn't come in the room when the patient rolled in the room.

Bottom line in my hospital, we'll try a labored COPDer on bipap first, hoping to not have to intubate them, but sometimes you do intubate no matter what. I think from what you've described, this patient may have been one who got intubated regardless of what happened. If he was labored and only able to answer yes/no questions, the pressure of the bipap is probably not gonna be enough to carry him through. One question though, I'm assuming respiratory got some gases on him. What did those look like? We usually get an ABG when they come in, they get one an hour or two after on bipap to see if the bipap is effective.

If you got the ABG results after he had been on Bipap for sometime, and they were not really improving, then maybe you could've went to the doc with those and asked about the patient getting a unit bed, based on his ABGs, respirations continuing to be labored, decreasing ability to exert himself even answering questions, etc. That way, you have something to go along with your instinct that he's not a stable floor patient.

I woudn't give it another thought, except be more careful when I transfer patients to that floor to yell so everyone can hear me "the new patient is responsive, I'm leaving now" :rotfl: I think you did a great job, just remember your confidence in your nursing skills is very important. Don't let another nurse make you doubt yourself when you know in your heart you did the right thing by your patient.

[DR2004RN]

Thanks for your kind words that makes me feel better....some. Yes I will admit, I can improve on the next situation I am sure not to let this happen again.

You've already thought of a couple of ways to improve the next time even though you didn't make a mistake. You can be my nurse any day.

OK, let me get this straight. You got the patient to the bed, made sure he was satting ok, and gave nurse-to-nurse report. When you left the patient, he was not unresponsive.

Now to fill in the blank: Sounds like that nurse carried on with another patient. A THIRD nurse passing the room saw the patient in respiratory distress and made UNTRUE ASSUMPTIONS.

Over the course of the next few hours, everyone got the story straight. You did NOT abandon the patient. You did NOT fail to give report. You did NOT fail this patient in any way. The nurse you reported to should've gotten him an O2 tank. And it woud've been nice if the Respiratory Therapist accompanied his transfer since the patient really should've been on the bipap, but that's not always possible and you did nothing wrong.

Therefore, please stop beating yourself up about it, ok?

You've already thought of a couple of ways to improve the next time even though you didn't make a mistake. You can be my nurse any day.

[Mystery5]

Well, in my mind this was my worst mistake:

I had a pt in room and another nurse had the other pt. Where I work we get report on all the pts on the floor. The other pt was endstage COPD, no code, not expected to survive much longer, receiving Morphine nebs to ease resps, on a non-rebreather mask etc...

My pt was a diabetic, and I went in to do a blood sugar. I closed the curtain and proceeded to do it. I heard all this commotion in the next bed, and continued to do what I was doing. After finishing, I glanced at the other pt, who was in the bed near the door, on my way out. I noticed he was uncovered, and quickly covered him as I walked out.

Well, it turned out that he had died!!! I'm sure he died while I was in the room, I do remember his mask was off as I walked out, but it hadn't even registered. As far as repurcussions to the pt, he was expected to die, probably that day, but still, I can't believe how unobservant I was.

Lesson learned: always pay attention to the other pt in the room, even if he's not yours...

[UM Review RN, ASN, RN]

I did think though, that he was exhausted from working so hard to breathe. This is why I feel incompetent and like this was all my fault.

No, it's not your fault. It does take an experienced eye to "just know" that the patient is in trouble. I remember one patient I had who simply sat on the edge of his bed working so hard to breathe--but he was satting in the 90's.

His respirations were high and he looked awfully ashen. His lungs were clear.

I decided to keep a really close eye on him, especially when he said he was OK.

Two hours into the shift I couldn't take it anymore. The guy had been like this all day long. I called the Respiratory Therapist and together we called the Doc and got this fella a bipap and a Unit bed by telling the Doc that we were positive that his heart couldn't take this strain. The stat ABGs we did were not bad, either. But the patient was exhausted, unable to lie back at all, and had labored tachypnea and he looked like he was gonna Code on us at any time.

I went in and explained to the patient what we were going to do and how it would help him breathe. He was a little scared, but decided to trust me.

Well, wonder of wonders. We got him to ICU and once on the bipap, the man could actually LIE DOWN and REST. He smiled and gave me a big thumb's-up as I was leaving the unit. They kept him up there for a few more days and when he came back down, he was a new man.

You just never know with some folks, and end-stage COPD'ers are tougher than most.