Would You Blame This RN or Look Deeper?

[BethBoynton]

In this compelling Ted Talk, Leilani Schweitzer, tells us about the death of her little boy, Gabriel after a series of medical mistakes. He was 20 months old when his heart stopped while hospitalized.

All of the alarms that he was hooked up to had been turned off by a nurse with devastating results. Although this happened more than 10 years ago, much can be learned from this. (If you can, please find 15 minutes to listen to her TED Talk.)

[video=youtube_share;qmaY9DEzBzI]

Leilani is articulate and despite unimaginable emotional pain does not blame the nurse. She understands, at least to some extent that this was a systems failure and has a compelling message about the importance of three components of medicine:

• Transparency
• Compassion
• Truth

In this case, all three were utilized in one of the two hospitals involved in Gabriel's death and contributed to quality improvements in the alarm design and some healing for this Mom. I also see a fourth and somewhat elusive component: the need for emotional intelligence (EQ) for nurses. Not only so that nurses will speak-up as patient advocates, but for themselves and their colleagues too!

In this case, how does a highly trained professional get to the point where she would do something that appears so egregious? Part of the answer lies in having the self-awareness and self-respect to say:

• I'm having a hard time thinking with all of these alarms and interruptions.
• I'm too tired to work overtime.
• I need help. and ultimately: We need help.

Or to have a colleague say:

• You look exhausted!
• It is hard for me to concentrate with all these interruptions too!
• What can I do to help?

Or to have a manager say:

• [to staff] Let's see what we can do to address the frequency of alarms on the unit.
• [to senior leaders] We need to consider technical and staffing solutions to address the frequency of alarms distracting our frontline staff.

All of these arise out of a respect for 'self'' and 'others' that is critical for patient safety and for sustaining long-term rewarding careers. Nurses must be able to set healthy limits, to have these limits respected, and to work in cultures where respect is the norm.

It would be easy to be aghast at the nurse's action. Who could justify turning off an alarm, not just at the bedside, but the nurses' station too? She shouldn't have. That's obvious. But seeking to understand the individual and organizational factors that contributed. Did she have alarm fatigue? Was there a history of false alarms with this and other patients. That shift? That day? That unit? Was understaffing contributing to excessive interruptions and distractions? Was this nurse on chronic 'overload'?

Understanding how unnecessary interruptions, such as false alarms or alarms that are in place as a substitution for adequate staffing is hard to quantify yet there effect can have a profound impact on our ability to concentrate.

Over the last decade there has been an increased focus on training nurses in assertiveness. Yet available models such as TEAMSTEPS, SBAR or ISBAR focus on speaking up to physicians and others for patients. This is only part of building true assertiveness and I advocate for a deeper process that involves emotional intelligence. A process that medical improv is perfectly suited for and where nurses develop self-awareness self-respect, and respect for others, including colleagues. I don't think we can optimize safe care build safe cultures, or sustain longterm, rewarding careers without it. What do you think?

[CrankyMa]

Safe Staffing Saves Lives

"Insufficient nurse staffing is linked with poorer patient outcomes, lengthened hospital stays and increased chance of patient death." (American Nurses Association).

There is much research to show that this is true. There are two bills about staffing and staffing ratios that need public support.

Please call your Senators and House Representatives about supporting:

*House Resolution 1602 (called H.R.1602 - Nurse Staffing Standards for Patient Safety and Quality Care Act of 2015). Read it here: www.congress.gov/..., and

*Senate Bill 864 (called - National Nursing Shortage Reform and Patient Advocacy Act). Read it here: www.congress.gov/...

Use this link if you don't have your Congresscritters number handy: whoismyrepresentative.com

A call or an email could make a big difference in your life or the life of someone you love (be it a patient or a nurse).

I have been at my current nursing job for 20 years. Even after 20 years I still love my job. I love it and plan to stay.

But a few weeks ago I had far too many patients to care for. This happens far too frequently these days. I spent the day putting out fires, catching up, treading water, attempting to keep up, and looking for help from colleagues who were often too busy themselves to provide the assistance I needed.

During this 12 hour day (Which are never 12 hours. It's always more than that.), I spent my 30 minute lunch break hiding out in the rest room where I hung my scrubs up to air out and took a bird bath. I left that night crying and well over two hours late. I kept detailed notes all day so I could focus on patient care and then spent the two hour overage documenting that care. This is a terrible way to work. Thankfully my patients were stable for the most part, but just one crisis would have affected the care of all the others in a negative way.

Just to be clear- I have been at my job, in the same unit, and the same facility for twenty years. I know my job very, very well. There is a national nursing shortage, patients are sicker, and money is tight. I understand that. But ask yourself 'If a long-term, knowledgeable, and efficient nurse can't manage his or her patient load, what kind of care would I or could I expect as a patient?'

Certainly not all days or all facilities are like that, but too many of them are. I have seen and felt the changes over my many years of practice.

My dad died due to poor medical care several years ago. The root cause of his preventable death was poor staffing. The experienced nurses had far too many patients to care for and missed important clues to his condition because they simply did not have the time to devote to his care that he needed.

Safe staffing saves lives. Please call or write. Do it now so you won't forget. It only takes a could of minutes.

[Janetnzrn]

I don't know PICU alarm settings, but on NICU there is NO customising of alarms. Everything has set limits which are evidence based. The only time I've turned alarm limits down or off is for a dying infant with the agreement of the parents and medical staff.

[KRVRN, BSN, RN]

I don't know PICU alarm settings, but on NICU there is NO customising of alarms. Everything has set limits which are evidence based. The only time I've turned alarm limits down or off is for a dying infant with the agreement of the parents and medical staff.

Exactly. And the upper sat limit is never off or 100 unless the baby is on 21%. Even 25% and they have to have their upper limit tightened. Alarm fatigue is a huge problem in NICU, especially when they aren't in private rooms and they all constantly desat and oversat.

[Sensibility, BSN, RN]

I wish this mom could read what I have to say. I am a pediatric nurse. This story is not only a cautionary tale for nurses but parents. As a nurse, I have been told by more than a few parents that they did not want me as their nurse. And why? Well, because unlike Mrs. Schweitzer's nurse, I would have worked on correcting the problem with the monitor and told the mom that it has to be on regardless of how often it alarms. I would have apologized for the inconvenience but that it was necessary especially if Gabriel was having seizures or something of that nature. I am jumping to a conclusion because he was being seen by neuro-surgery. This may not have changed the outcome but it would have surely been one less thing to say we did wrong. And she would have requested another nurse because, as she stated, she was tired and weary and she wanted to rest and that nurse was trying to help her to give her good customer service. At what point can a parent see that it isn't about them but about the baby? I am in no way blaming this mom. I am saying that this is a golden rule that is forefront in the hearts of many pediatric nurses. I have had this negative reaction happen over co-sleeping with small babies in a bed, coming to bedside too many times to deal with IV meds, speaking transparently about what is going on, and trying to intervene when a child, for example, had a fever that was not being controlled by the meds and I wanted to give a bath to get that high fever down. Do you know how many babies have died in the home because the parent rolled over on them while they were sleeping? Too many. And yet, these parents insist on sleeping with the baby. I have been given a hard time for sharing side effects of meds even though the new laws stipulate that we educate parents on this. Parents complain, request another nurse who will give them a positive story and not share what's going on and they get what they want. I have only once gotten an apology by a parent and it was not the one that actually blew up at me. I have had them walk out the door with their nose in the air. I have had nurses who comply with parents every request pridefully tell me that they never have that happen. And yet, it is stories like this that encourage me to continue to attempt to help parents see the need. Thankfully, I can see though how my kind efforts do change the course of events, the issue becomes safe, the child is safe and I am rejected. So the outcome is encouraging to me. I wish the parents wouldn't do that though. I often tell people that I hate the scenario where I am called into an office and told, "You knew that this was what you were supposed to do and what were you thinking?" With a child, there is no grace. See, I can imagine a parent rolling over on their child and me getting the blame. Pediatric nurses are restricted by demanding overbearing parents. We must comply with most requests because parents and patients have rights. They can refuse meds. They can refuse tests. They can refuse the monitor. They can diss nurses. They can speak disrespectfully to us. But you let something go wrong and look where the finger is pointed. Does this mom take any responsibility for what happened? Did she say something to that nurse that caused the nurse to try to help her? No, she is now the wounded person and WE were supposed to know better. Now today, thanks to Obamacare, these same parents within the next few years will be able to express their dissatisfaction with our compliance to their every desire. If we get a low score, supposedly, Medicaid will not pay for the full hospital bill. As I said, I wish more parents could hear this because perhaps one in a hundred thousand will be like Gabriel. But it only takes one to get us to see that safety is more important than making a hospital stay seem like a luxury vacation at the Ritz. It is never pleasant to have a sick child because children get pinched and poked and nobody wants to see their child go through that. What parents need to see is that we are not trying to hurt that child. We are trying to help them. I would have further asked this mom if someone else could stay at bedside while she went home and got some rest. In our unit, we have encouraged parents to leave to go home and get rest. Our unit is secured and locked. And we take good care of our babies. I am truly sorry for your loss. So sad.

[jdub6]

I may have missed it but nowhere did I see or hear that this baby was "critically ill" as others have implied. When working in the picu with critical pts we never disabled alarms. But when working on the pediatric floors with sick non critical pts, even if the alarms were on the staff was often busy attending to their 4 or 5 or more other pts to notice. I once took care of a girl who had been having runs of life threatening arrythmias for DAYS, on the monitor, alarms on, on the floor. No one noticed because false arrhythmia alarms are so common and they all had other pts, and no one was necessarily near the room or at the station to hear the alarm.

That pt also died although it was after being transferred to icu when someone reviewed the alarms and realized these were real and had been for days. She easily could have had that last fatal episode on the floor and been ignored until it was too late, and the nurses blamed for not seeing the alarm- no one would have known she would have died anyway.

With more and more sick pts being placed on floors where nurses have 5 to 10 pts who may all be on at least continuous 02 monitors, and no monitor tech, this is bound to happen. Of course there will always be the errant tragedy of the pt who WAS stable for the floor until they weren't, but I think many floor pts are at great risk, which is why they are on monitors. But there has to be someone there to watch the monitor. And a nurse who is constantly responding to one, or 4 pts who have frequent false alarms is going to be distracted from other important tasks, so I do think that this nurse may have been in an unsolvable situation. (From the video I understood that the nurse did not realize she was turning off all alarms, from my understanding she intended to silence only the monitor in the room. If she was working with a pt sick enough to be monitored she should have known how to use the monitor, but maybe she wasn't fully trained, or maybe she was a float? I could see this happening easily when staff are pulled to unfamiliar areas regularly. )

I don't know all the details but I can see how this could easily have happened without gross negligence (a mistake, yes...again she obviously didn't completelt know how to use the monitor, but mistakes happen and sometimes we are set up for them. ) I don't mean to defend the nurse necessarily. Just being the Devils advocate.