Tuesday, October 12, 2010


Heyooo! Sorry I was gone for a while. I decided it would be fun to take a two week vacation to EUROPE! So I did. And now I'm back. Huzzah!

There are many oopsies that occur in life. Most of them are inconsequential; some are not. Accidentally tucking your dress into your underwear is an embarrassing but relatively minor oops. Being Britney Spears and neglecting to wear underwear at all is an arguably major oopsie.

In medicine however, oopsies are a much bigger deal - no matter how small they might seem at first. If you chart that an ailment is on the left side instead of the right, it was probably just a typo on your part, or clicking on the wrong spot on the assessment page. But if that chart gets audited, your little oops now questions your competency. If your patient is rude and obnoxious and calls you names and you accidentally snark back, well, if they take it to management and then your little moment of oops now goes on your record as "unable to communicate effectively with patients." If there is an order from a doc for an insulin R drip at 5 u/hr, and you accidentally give 5 units IVP then catch it an hour later, you are still expected to write yourself up for that oopsie. Management says it won't be counted against you, since you voluntarily wrote it up, but lets be real - that sucker will factor into your performance ratings without fail.

So hospitals are a funny place - you do a thousand things correctly without mention, and one thing goes wrong and it's a major oops. But what if the patient actually causes the oops?

What happens when the patient accidentally decides their neb treatment is done? What happens when they decide their treatment is no longer necessary? What happens when they decide to take their Bipap machine and attach it to their face, even though there is no O2 flowing through it?

Yeah, that happened.

We had a patient who was pretty sick. Nice, sweet lady who just couldn't breathe. It's right at change of shift, and the offgoing nurse is giving report on her. Everyone is standing at the nursing station going through the chart, and they notice her O2 sats dropping. "She's been on Bipap but Respiratory just pulled her off for a minute for a neb treatment. She's been hanging in the low 90's all day," says the nurse.

We look at the monitor for about 10 more seconds, then troop over to the room because while she's been low 90s, 88 is too low for her. By the time we get to the room, her sats are 70. She looks like a dying fish, gasping for air behind her Bipap mask. We start to scramble, because this lady is getting intubated, we just know it. One nurse grabs the intubation box, one gets the doc, and another pulls the BVM off the wall. We're ready.

And then someone notices that the patients neb treatment is still running. Not attached to to the patients face, but still running. And then someone else notices that the Bipap is on, but the O2 isn't on. So now the primary nurse is confused, and everyone is pissed because someone, somehow, was stupid enough to put the patient back on bipap and not turn on the oxygen, and do it all before the neb treatment was over.

The respiratory therapist swore up and down that two minutes ago, the patient was on the neb treatment and doing fine. The offgoing primary nurse swears that the patient was on a working bipap before the neb treatment, which was the last time he was in the room. No one can figure out what happened, and we're all upset because this is a big oops and someone is going to get it.

Meanwhile, the bipap O2 was turned on, and the patient perks right back up. When she is well enough to talk again, we ask her what happened.

"Oh, I was tired of that nebulizer treatment; they always make my heart race. So I just took it off and put that mask back on my face, and turned the machine on."

Silence. We all stare at her, and it dawns on us - this lady damn near suffocated herself. She did the equivalent of putting a plastic bag over her face, which is what a nonworking bipap mask amounts to. The worst part? Had we not caught this sooner, she would have died. And there is no way, no way the hospital would have ever figured out what happened. It would have been us to blame for this major oopsie, even though we had no fault at all.

Just goes to show you, no matter how careful you are...a minor oopsie can become a major one and patients can commit their own oopsies that can drag you down with them.


Maha said...

Oh. My. Gawd. That's insanity. I hope the oncoming shift made it a point to tell that patient that she nearly killed herself. And you're absolutely right - if she actually died, the primary nurses would have gotten hell for it forever.

Aspiring2Be said...

Oooooh great story - thanks for sharing. Just a little something extra to watch out for!

Laney said...

Oh wow, that's insane! Great reading :)