Incident Reports

[PainDrain]

So I have gotten written up by nurses in "incident reports" a few times over the years and I cannot for the life of me figure out the reasoning behind this utter bull****. My write ups have mainly come from OB. To elaborate, I was first written up for an epidural that despite repeating it 3 times had a persistent right window and I offered the patient (who at that point was 10cm and starting to push) a spinal, which I did and she was very comfortable. The report said it was for "inadequate labor analgesia".

Next, I had a c-section under epidural where the young patient was complaining of severe pain. I asked the nurse that the boyfriend be taken out so I could give the patient my full attention if I needed to go GA. The nurse refused and when I raised my voice asking again apparently that was grounds for being written up. I was also written up another time for being told that the patient was in the OR (without me or another anesthesia provider) for her elective c-section despite the fact that I told them before it was inappropriate to bring the patient to the OR before I had the chance to interview and examine her.

In the OR I have been written up for a case of severe bronchospasm in a pedi case where I called for backup and another case where I converted from an LMA to an ETT because the patient desatted.

Am I missing something here or is this nursing driven bull**** out of control?

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[ranvier]

I think it is out of control.
The OB world is a special kind of crazy.

 

[aneftp]

Welcome to the world of "metrics"

Hospitals and their nursing staff mid levels managers are told my higher ups to tow the company line on "patient satisfaction" if patient not satisfied and pain is (was a metric). Than they gotta find someone to blame (anesthesia)

 

[IlDestriero]

So I have gotten written up by nurses in "incident reports" a few times over the years and I cannot for the life of me figure out the reasoning behind this utter bull****. My write ups have mainly come from OB. To elaborate, I was first written up for an epidural that despite repeating it 3 times had a persistent right window and I offered the patient (who at that point was 10cm and starting to push) a spinal, which I did and she was very comfortable. The report said it was for "inadequate labor analgesia".

Next, I had a c-section under epidural where the young patient was complaining of severe pain. I asked the nurse that the boyfriend be taken out so I could give the patient my full attention if I needed to go GA. The nurse refused and when I raised my voice asking again apparently that was grounds for being written up. I was also written up another time for being told that the patient was in the OR (without me or another anesthesia provider) for her elective c-section despite the fact that I told them before it was inappropriate to bring the patient to the OR before I had the chance to interview and examine her.

In the OR I have been written up for a case of severe bronchospasm in a pedi case where I called for backup and another case where I converted from an LMA to an ETT because the patient desatted.

Am I missing something here or is this nursing driven bull**** out of control?

I don't understand any of these things you wrote. None would have generated a report anywhere I worked. It sounds like you're doing the right thing. Keep it up and **** them. Though don't raise your voice angrily or you'll be hanging in HR taking some anger management and conflict resolution classes. Next time assign the task to a nurse by name. "Nurse Jenny, the patient's significant other needs to be escorted out immediately."


--
Il Destriero

 

[Psai]

Real question is what happens? Nothing? Does your chief talk to you?

 

[NightNight]

Disclaimer: I don't know you, and I'm sure you are a great guy and practice effective and safe anesthesia with the best of 'em.

Maybe, just maybe, you don't have great "people skills". I could be 100% off base and it could just be a nursing thing at your place, but in my experience the guys (or gals) who are constantly running afoul of the clipboards just can't (or won't) find that special zone where the patients are safe and the checklist-makers are happy.

I'm just saying, maybe.


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[dmk5n]

Nursing driven bull**** out of control. I feel like it's seventh grade all over again.

 

[drmwvr]

It's "nursing empowerment" culture...and the conventional wisdom among nurses that if they don't understand something, there is something wrong. That's why there are more of these "events" generated in the less skilled areas of nursing (OB)than higher skilled (ICU) areas.

 

[PainDrain]

Disclaimer: I don't know you, and I'm sure you are a great guy and practice effective and safe anesthesia with the best of 'em.

Maybe, just maybe, you don't have great "people skills". I could be 100% off base and it could just be a nursing thing at your place, but in my experience the guys (or gals) who are constantly running afoul of the clipboards just can't (or won't) find that special zone where the patients are safe and the checklist-makers are happy.

I'm just saying, maybe.


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My personality isn't an issue. I have never thrown tantrums or some other BS that would have resulted in these issues. Other docs have clearly done some stupid things and it has also gotten them written up, but these were serious issues. I am being completely honest in what I wrote above. I honestly couldn't believe these instances resulted in a report. One instance I literally walked into the OR after being paged to meet a patient for an elective section and I was made out to be the bad guy because I asked that the OR not be the first instance I met the patient. I literally had no info on her, zero. First baby, no fetal distress and it was being done because of patient preference. Wtf.

Bronchospasm happens all the time. Changing out an LMA to an ETT???

 

[NightNight]

Fair enough. Just throwing it out there. I deal with tons of nurse related stupid bull s h it all the time (especially as a CA3 who has been doing it long enough to call them on their crap but still a resident) so I believe you for sure.


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[NightNight]

What was the write up reason given for securing the airway???? That's crazy.


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[deepstate2016]

I have been written up for more buckshot then I can count. Incident reports are now a way for these nurses to harass others including each other. The original intent was to highlight safety concerns. Guess what not anymore.

 

[narcusprince]

Idesterio I was written up for calling a nurse excuse me nurse so you know where the consent is.....

 

[GravelRider]

This is our new reality. We let this happen. Nurses hold the power now. The clipboard crew was unleashed to suppress doctors and make us tow the line. If you show any sign of dissent, you will be labeled a "disruptive physician." The hospital wants us to be sheep so they can control us.

We need to fight this. Everytime a nurse does something dumb then you should write them up. If there is a compromise to patient care then you need to make that known. Tell the patient, report the nurse, become a whistleblower, whatever it takes.

 

[pjl]

I would have a different person evaluate your people skills, and tell you if you are not acting in a way that fits the culture of the institution.

We have a CRNA that gets written up for similar BS reasons that I know are well within the standard of the group. Despite being a good guy in my opinion, for whatever reason he creeps out some of the nurses so they write him up for the smallest things. The complaints are, of course, silly and unfounded, so we tell him he got written up, work with him on presentation skills a little and send him back out there.

You dont SOUND like you are doing anything wrong in your version of it, so if those facts are accurate, you may be running into the personality concerns discussed above. You need an honest friend at the hospital to answer this, and the willingness to seek out the answer. Beware though that most will be uncomfortable telling you if you are doing something that makes people uncomfortable so it is hard to get a good read on it.


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[deleted59964]

the problem here is that incident reports are being used as a weapon, not as intended, a method of improving quality and safety.

people who submit incident reports that are clearly vindictive should be dealt with as troublemakers, told they are abusing a system that is designed to ensure safety, and that it will not be tolerated.

 

[Man o War]

I have found this phenomenon to be very institution/culture dependent. The funniest write up I ever got was during my cardiac fellowship. My first week I got a write up for "tangled, messy line set up". So absurd it was funny. I also once got written up for walking away from a nurse aggressively. I'm not kidding, that's what it said.
I have not had any issues with this at my 2 other long term places of employment.
This is their way of exercising the only slice of "power" they perceive to have. It's very annoying, and childish on their part.
I've noticed they love to write up CRNAs too. Very odd dynamic between nurses and CRNAs, especially on OB.

 

[partydoc]

I tried to write up a nurse the other day, I really tried my best. But the pages of bullsh*t I had to fill out on the computer, I just gave up and proceeded to actually take care of my patients.

 

[Promethean]

I don't deny that there are nurses out there who are using them the wrong way, who are "writing people up," rather than reporting incidents.

That said, I once used the report appropriately, to document an instance of a resident giving a patient a drug to which they were allergic (anaphylaxis.) I tried to write it in a way that made the resident sound as if he had been the one who caught the mistake and was the hero of the situation, but I was absolutely obligated to write it and would have been disciplined had I not done so.

Still, the attending on the case physically backed me up into a corner and screamed in my face for 45 minutes (no exaggeration) that I had no right to judge the actions of the physician, and that, as just a nurse, I couldn't have possibly understood the medical reasons that the drug might have been administered. There was no medical reason. The drugs were being administered to the patient before anyone opened her chart.

There were protocols in place that were supposed to have prevented things like this from happening... like doing a quick time out when the patient came into the room, to assure that we had the right patient, were going to do the right procedure, and what allergies and other risks they might have. It was this doctor's practice to come flying into the room, "forgetting" the patient's chart back in preop, and then to have her resident start giving meds for the induction while telling the nursing staff that if they wanted to look at the chart, they'd better send someone to fetch it. She was routinely ignoring protocols that were put in place to assure patient safety, and it finally came back to bite her. So her response to that was to bully the nurse who reported it.

So, there really are problematic physicians out there, who really do compromise patient care. There needs to be some way to address that. Incident reports are what we've come up with. They aren't perfect and can be misused, but so can any tool. I'm truly curious how people who are opposed to incident reports believe that such situations should be handled instead? And what should be nursing's role in a situation like this?

 

[Noyac]

I didn't read all of the comments so if this has been said then I apologize for repeating it.

I have been in practice for over 10yrs and I have never been written up. It sort of amazes me that anyone could be written up as many times as you stated. It makes me think that there is something going on. Either you are unaware of your interactions which you say is not the case or your nurses work in an atmosphere of Doctor bashing and harassment.

Solutions would be:
1- work on your approach which is always a good solution even if you are not the issue here.
2- visit the nursing supervisor and possibly the CNO. If you visit the CNO I would use terms like "harassment" and "hostile work environment". These terms get people's attention and they must act. If you are serious about it, put it in a formal complaint letter.

Also, remember to never confront a nurse or physician for that matter in front of the pt. either continue on with the pt or ask the nurse to step outside for a minute. In the case where they brought the pt into the OR before you saw her, I would have continued with the pt until the case was over and afterwards I would have addressed the issue with the eh staff. This accomplishes two things. First it allows you to cool down and secondly, the pt is the main focus until the case is over.

Finally, work on your epidurals . That's a joke.

 

[caligas]

I didn't read all of the comments so if this has been said then I apologize for repeating it.

I have been in practice for over 10yrs and I have never been written up. It sort of amazes me that anyone could be written up as many times as you stated. It makes me think that there is something going on. Either you are unaware of your interactions which you say is not the case or your nurses work in an atmosphere of Doctor bashing and harassment.

Solutions would be:
1- work on your approach which is always a good solution even if you are not the issue here.
2- visit the nursing supervisor and possibly the CNO. If you visit the CNO I would use terms like "harassment" and "hostile work environment". These terms get people's attention and they must act. If you are serious about it, put it in a formal complaint letter.

Also, remember to never confront a nurse or physician for that matter in front of the pt. either continue on with the pt or ask the nurse to step outside for a minute. In the case where they brought the pt into the OR before you saw her, I would have continued with the pt until the case was over and afterwards I would have addressed the issue with the eh staff. This accomplishes two things. First it allows you to cool down and secondly, the pt is the main focus until the case is over.

Finally, work on your epidurals . That's a joke.

Also, what's the big deal with doing a rare pre op in the o.r.? Obviously can't happen as a pattern but, if it's just once in a blue moon, think of it as an opportunity to start billing a few minutes sooner.

And DONT fight this by trying to write up nurses in revenge. You will create a losing battle. They will ****ing bury you in write ups.

 

[fakin' the funk]

So I have gotten written up by nurses in "incident reports" a few times over the years and I cannot for the life of me figure out the reasoning behind this utter bull****. My write ups have mainly come from OB. To elaborate, I was first written up for an epidural that despite repeating it 3 times had a persistent right window and I offered the patient (who at that point was 10cm and starting to push) a spinal, which I did and she was very comfortable. The report said it was for "inadequate labor analgesia".

Next, I had a c-section under epidural where the young patient was complaining of severe pain. I asked the nurse that the boyfriend be taken out so I could give the patient my full attention if I needed to go GA. The nurse refused and when I raised my voice asking again apparently that was grounds for being written up. I was also written up another time for being told that the patient was in the OR (without me or another anesthesia provider) for her elective c-section despite the fact that I told them before it was inappropriate to bring the patient to the OR before I had the chance to interview and examine her.

In the OR I have been written up for a case of severe bronchospasm in a pedi case where I called for backup and another case where I converted from an LMA to an ETT because the patient desatted.

Here's my hot take.

The things you describe sound reasonable -- undesirable/suboptimal, but in the normal course of care, reasonable.

But YOU are getting written up for these things and others aren't. YOU have to ask why that is.

To me this pattern means either
a) your reputation at your institution is poor, so when suboptimal things happen, it is attributed to you as opposed to being deemed "unavoidable." This happens when you're new. At my gig, when you're new and some crazy $hit happens, it's because you're inexperienced, don't know your way around, a personal failure, etc. But if you're senior and people know you and some crazy $hit happens, that's deemed "unavoidable."
b) your interactions with staff are received poorly -- whether or not you truly are being negative, rude, etc, etc.
c) your hospital culture is just hella toxic.

Probably a little of all 3. But since only YOU are gonna be able to fix the problem, work on your treacly sweet personality, let everyone know if a case is gonna be difficult/tricky so that it's not unexpected or viewed poorly of you when it is, don't retaliate, and if you have an issue with a particular nurse, discuss it with that nurse with either the nurse's supervisor or at least in earshot of other individuals who you can count on to have your back (NOT alone one-on-one). Good luck.

 

[Arch Guillotti]

Disclaimer: I don't know you, and I'm sure you are a great guy and practice effective and safe anesthesia with the best of 'em.

Maybe, just maybe, you don't have great "people skills". I could be 100% off base and it could just be a nursing thing at your place, but in my experience the guys (or gals) who are constantly running afoul of the clipboards just can't (or won't) find that special zone where the patients are safe and the checklist-makers are happy.

I'm just saying, maybe.


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Maybe.

Nurses are trained to file incident reports when something is unusual or out of their "comfort" zone. If you rub them the wrong way in the least bit you may have problems.

The best advice I can give you is to think very carefully before anything you say or do and how it can be perceived because image is everything.

 

[IlDestriero]

The best advice I can give you is to think very carefully before anything you say or do and how it can be perceived because image is everything.

And fill up the trough every once in a while.
It goes a long way.


--
Il Destriero

 

[Arch Guillotti]

And fill up the trough every once in a while.
It goes a long way.


--
Il Destriero

Kill them with kindness.

 

[Promethean]

And fill up the trough every once in a while.
It goes a long way.
--
Il Destriero

Is this why my anesthesiologist friends were always so happy to have me order lunch for the weekend crew on their dime?

Y'all really don't have to give over your credit cards to buy goodwill. I mean, take out is nice and all, but just being pleasant and showing a little respect for patients and the people you work with is a lot cheaper and probably more effective.

Buying me food wouldn't keep me from writing an incident report if it were warranted. But if a usually kind and patient-focused doc were just having an off day, I'd be very careful not to throw them under the bus if I could help it.

 

[Mad Jack]

Welcome to the world of "metrics"

Hospitals and their nursing staff mid levels managers are told my higher ups to tow the company line on "patient satisfaction" if patient not satisfied and pain is (was a metric). Than they gotta find someone to blame (anesthesia)

Rather amusing, considering patient satisfaction is inversely correlated with patient outcomes. They'd rather have happy patients than healthy ones.

 

[Promethean]

Rather amusing, considering patient satisfaction is inversely correlated with patient outcomes. They'd rather have happy patients than healthy ones.

Happy, unhealthy patients want to keep coming back to your facility for all the additional services they need, thanks to your kind and accommodating mismanagement.

 

[Ezekiel2517]

Not just our specialty, but medicine in general, has come to the point where the least knowledgeable and lowest trained people can judge the most highly trained/knowledgeable. But it happens more in our field cuz most anesthesiologists are a bunch of bitches. In fact, being a bitch is required to be successful in PP. When I'm in the unit, I don't see anywhere near the level of disrespect I have seen anesthesiologists receive. And ICU nurses are far more trained and smarter than the dolts in the OR/PACU/OB. All these reports you talk about won't turn into anything substantial dude, trust me. Why? Because you kept the pt safe. Just keep the pt safe, it trumps everything else. And just smile and fake it and apologize if needed when they talk their BS. Just think about how you'll be laughing your way to the fukn bank (hopefully you're making decent dough). I'm assuming you're in PP, trust me this isn't worth fighting.

 

[pulmoblast]

Ah nurses ...

Can't live with them
Can't live without them




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[caligas]

It is a possibility to have an administrator look into a nurses reporting history to see if there is a pattern of abusing the system.

 

[Gas you down]

I don't deny that there are nurses out there who are using them the wrong way, who are "writing people up," rather than reporting incidents.

That said, I once used the report appropriately, to document an instance of a resident giving a patient a drug to which they were allergic (anaphylaxis.) I tried to write it in a way that made the resident sound as if he had been the one who caught the mistake and was the hero of the situation, but I was absolutely obligated to write it and would have been disciplined had I not done so.

Still, the attending on the case physically backed me up into a corner and screamed in my face for 45 minutes (no exaggeration) that I had no right to judge the actions of the physician, and that, as just a nurse, I couldn't have possibly understood the medical reasons that the drug might have been administered. There was no medical reason. The drugs were being administered to the patient before anyone opened her chart.

There were protocols in place that were supposed to have prevented things like this from happening... like doing a quick time out when the patient came into the room, to assure that we had the right patient, were going to do the right procedure, and what allergies and other risks they might have. It was this doctor's practice to come flying into the room, "forgetting" the patient's chart back in preop, and then to have her resident start giving meds for the induction while telling the nursing staff that if they wanted to look at the chart, they'd better send someone to fetch it. She was routinely ignoring protocols that were put in place to assure patient safety, and it finally came back to bite her. So her response to that was to bully the nurse who reported it.

So, there really are problematic physicians out there, who really do compromise patient care. There needs to be some way to address that. Incident reports are what we've come up with. They aren't perfect and can be misused, but so can any tool. I'm truly curious how people who are opposed to incident reports believe that such situations should be handled instead? And what should be nursing's role in a situation like this?

what was the drug and allergy

 

[deleted50478]

what was the drug and allergy

Probably a vague story of mild penicillin allergy from childhood and ancef.

 

[Planktonmd]

The one thing they don't teach in medical school or residency is how to keep the nurses happy!
You need to learn the art of BS, remember their names, know their kids names, throw complements at them, buy them food, and above all listen to them.
This is how you get on their good side and become the good doctor who does no wrong!

 

[Onefellswoop87]

The one thing they don't teach in medical school or residency is how to keep the nurses happy!
You need to learn the art of BS, remember their names, know their kids names, throw complements at them, buy them food, and above all listen to them.
This is how you get on their good side and become the good doctor who does no wrong!

Actually that's been beat into some of us since med school. I graduated in 2013 and had a few talks/"lectures" between 1st and 2nd year about the importance of keeping nurses/ancillary staff happy. It was also a common informal talking point on the wards in med school and internship.
You also can't scan through a blog (such as kevinmd) without seeing such writings frequently.

 

[Noyac]

Just keep the pt safe, it trumps everything else. And just smile and fake it and apologize if needed when they talk their BS. Just think about how you'll be laughing your way to the fukn bank (hopefully you're making decent dough). I'm assuming you're in PP, trust me this isn't worth fighting.

This is not necessarily true anymore.
Non medical members of administration will place greater emphasis on playing nice than they will on safety. Outcomes matter somewhat only because payments will be tied to it. These are business people and they don't think along the lines of pt care and outcomes as much as we do. It is s fools game to think that if you are a great Doctor and your pts do well that you are safe. As far as these administrators go, they feel that anyone can be replaced and they won't hesitate to prove it.

 

[GravelRider]

This is not necessarily true anymore.
Non medical members of administration will place greater emphasis on playing nice than they will on safety. Outcomes matter somewhat only because payments will be tied to it. These are business people and they don't think along the lines of pt care and outcomes as much as we do. It is s fools game to think that if you are a great Doctor and your pts do well that you are safe. As far as these administrators go, they feel that anyone can be replaced and they won't hesitate to prove it.

This is true. If you get enough of these write ups then you will be labeled a "disruptive physician." Some hospitals will even make you pay for courses on how to work well with others.

Physicians have historically been difficult to control. The clipboard crew and ridiculous regulations were unleashed in the name of improving quality and patient satisfaction. In reality this was done to make physicians more docile. In the northeast we are seeing absurd regulations being put in place regarding OR attire. There is not an a single line of data supporting these regulations. However, they are being put in place to control the group of physicians who have historically been the most difficult to control...surgeons. So now instead of us focusing on the patient we get chased around by nurses with clipboards if you have an eyebrow hair exposed. If you don't have your 5 o'clock shadow covered up by 4 o'clock then you get written up. Everyone is so concerned about focusing on an ever increasing list of rules that we are losing focus on our patients. Just think about what happens in your hospital in days the Joint Commission or the department of health is coming to inspect. It is distracting. Now do that everyday.

 

[pjl]

This is true. If you get enough of these write ups then you will be labeled a "disruptive physician." Some hospitals will even make you pay for courses on how to work well with others.

Physicians have historically been difficult to control. The clipboard crew and ridiculous regulations were unleashed in the name of improving quality and patient satisfaction. In reality this was done to make physicians more docile. In the northeast we are seeing absurd regulations being put in place regarding OR attire. There is not an a single line of data supporting these regulations. However, they are being put in place to control the group of physicians who have historically been the most difficult to control...surgeons. So now instead of us focusing on the patient we get chased around by nurses with clipboards if you have an eyebrow hair exposed. If you don't have your 5 o'clock shadow covered up by 4 o'clock then you get written up. Everyone is so concerned about focusing on an ever increasing list of rules that we are losing focus on our patients. Just think about what happens in your hospital in days the Joint Commission or the department of health is coming to inspect. It is distracting. Now do that everyday.

I love when they tell me I cant wear a t shirt under my scrubs. I proceed to pull down my t shirt and ask if they want my chest hair to fall into their sterile field instead. This seems to work well, and everywhere they have tried to pass that stupid rule it has been rescinded after I ask in that way. Or one can point out how difficult it will be to concentrate with all the cleavage showing, but you risk being a little creepy.


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[sigrhoillusion]

I made the biggest mistake of my life as a resident when I wrote up a nurse. Nurses write people up left and right because they think they know evberything, but when the shoe is one the other foot it's uncalled for.

Of course we are entering the OB world, go figure... Story goes like all OB nurses they think their patients are the only patients and it's anesthesia's job to ask "how high?!" when they ask us to jump for them. So where I did residency the OB nurses would page us for everything and anything at all times, no matter how small they were. And they were notorious for writing up people for anything. Some how as a CA-3 I had avoided their wrath, but some of my colleagues had to have the "sit down" with either the usual attendings that covered OB or even the program director.

Well sometime during the 3rd week of my last month and final month of OB coverage (sans moonlighting), I decided to make a stand for my peeps! One day we were really busy and I think both CA1 and CA2 were in the OR doing sections, and I was running around placing epidurals, pulling epidurals, pre-opping and placing IVs on patients that the nurses failed at putting in themselves. So, backing up, the one thing that really bothered most of the residents was the fact that the nurses would demand things of us, even when they knew it was physically impossible for us to do them. You KNOW it's 1am and I'm stuck in this c-section and I can't abandon the patient, so why are you telling me that so and so patient needs something? Either wait until the section is done, call the 1st call resident to manage the other call people to possibly help out, call the anesthesia attending who's free, or perhaps stop playing Candy Crush and gabbing about your boyfriends in the lounge/work station and possibly comforting the patient yourself or figuring out another option...

So of course I'm running around and I get a call for an epidural placement. The nurse who calls me knows I'm in the NEXT ROOM placing another epidural. (This call couldn't wait 10 minutes? Maybe just ask me when I finish placing this one?) So I tell her I'll be a few minutes and to get the patient ready and I'll be there in a few minutes. So I place my epidural, dose it up, write my note and leave the room.

Luckily, I go into the next room and there's the patient sitting on the side of the bed, with nasal cannula O2 on, vitals up on the monitor, the nurse talking her through her current contraction and positioning her for a quick, successful epidural placement so she will be "PAIN FREE" thanks to the amazing anesthesiologists. I prep the patient, place my needle, get LOR and successfully place the epidural which takes away every pain fiber in the patients lower body. The nurse high fives me, the patient delivers her baby without pain or a need for a section. She even names her child after me, because of her eternal gratitude and that baby ends up going to Harvard and becoming the future President of the United States and eventually ending world hunger and creating peace on Earth.

Oh wait... that wasn't what f**king happened...! Instead I go into the room and the patient is lying in bed moaning a way with nothing set up. I go to the nursing station and of course that nurse is gabbing away with another nurse. I kindly state that I'm ready to place the epidural. She looks at me like I'm interrupting a life changing conversation (probably something about one of the Kardashian sisters) and tells me she'll be there in a few minutes. So I go back to the room, and talk to the patient, and get my equipment ready. Nurse finally comes in after a few minutes (and a few contractions) and I place the epidural. Not sure if that kid will go on to the successes I mentioned before, but it's the only thing that keeps me going in OB...

So after that I go on my hospital's reporting website and essentially write up the nurse for causing "undue pain to a patient" essentially making her suffer for 10 minutes. Why I did this? I don't know. Just blowing off 3 years of steam, and I'm pretty sure I got paged while placing that epidural as well, probably by the same nurse who was gabbing with the written up nurse despite knowing I was now with that nurse placing an epidural... So of course when I come into work the next day, there is a s**tstorm of angry nurses waiting at the anesthesia OB workroom where we all gather. How DARE I write up a nurse. That's not allowed!!! Of course I had to have a sit down with the nurse, her supervisor and my attending that day for about 30 minutes and have a little"hug it out" session. After they left, my attending was like "what a bunch of BS, but essentially just told me to hold it in next time to spare us from another ridiculous meeting." I did get some glares from some of the nurses over the next day or so, but surprisingly for about a week after that pretty much every epidural that we placed was all set to go within a minute of being called to place one, and the nurses even thanked us a few times. Mission accomplished I guess...

 

[Promethean]

Probably a vague story of mild penicillin allergy from childhood and ancef.

Nope. Sometimes allergies are real. Assuming they are all outgrown or adverse reactions just because so many are is foolish and likely to hurt someone.

The patient was allergic to glycopyrrolate. She'd had anaphylaxis to it after a surgical procedure the year prior. Some of our anesthesiologists provided it routinely as part of their standard inductions, so it was already drawn up and ready to go and no one thought to check that it was removed from the pile of syringes to be administered for that patient. This was a surgery center like environment, where patients were rushed in and out of procedure rooms quickly. PAs and NPs were doing pre-ops, residents and CRNAs were doing hands on, and the anesthesiologist was bouncing between rooms for inductions and extubations. In a situation like that, when people decide to start cutting corners and disregarding time out procedures, it is an invitation for disaster.

When I finally got the chart in my hands (I had to run back to the pre-op area to get it because again, this doctor had a habit of leaving it behind) and started calling out the "time-out" information, the induction was already underway. I got to the glyco allergy just as the resident had started pushing the med. Happily, she didn't get the whole dose. Unfortunately, she did get some, so that she did have a reaction and ended up needing treatment plus an unplanned overnight stay for obs for what should have been a same day/outpatient case. As I said before, when I wrote the report, I tried to let it sound as if the resident had been the one to identify the error and I carefully avoided throwing anyone under the bus. Not even the attending who later physically blocked me into a corner so that she could scream at me that, as an ignorant nurse, I couldn't understand the medical reasons for giving a patient a drug to which they'd previously anaphylaxed.

Again I ask... in a situation where there is real threat of harm to patients from ignored safety protocols, how would you prefer that nursing address a situation like this, if not via incident reporting? No one has answered that yet. I really am curious what else you think I should have done. There was no covering up what had happened, so if I didn't write the report, that would have been worse for everyone. I would have been disciplined for failing to report it and a lack of documentation is not a defense if the matter had gone to litigation.

 

[deleted50478]

Nope. Sometimes allergies are real. Assuming they are all outgrown or adverse reactions just because so many are is foolish and likely to hurt someone.

The patient was allergic to glycopyrrolate. She'd had anaphylaxis to it after a surgical procedure the year prior. Some of our anesthesiologists provided it routinely as part of their standard inductions, so it was already drawn up and ready to go and no one thought to check that it was removed from the pile of syringes to be administered for that patient. This was a surgery center like environment, where patients were rushed in and out of procedure rooms quickly. PAs and NPs were doing pre-ops, residents and CRNAs were doing hands on, and the anesthesiologist was bouncing between rooms for inductions and extubations. In a situation like that, when people decide to start cutting corners and disregarding time out procedures, it is an invitation for disaster.

When I finally got the chart in my hands (I had to run back to the pre-op area to get it because again, this doctor had a habit of leaving it behind) and started calling out the "time-out" information, the induction was already underway. I got to the glyco allergy just as the resident had started pushing the med. Happily, she didn't get the whole dose. Unfortunately, she did get some, so that she did have a reaction and ended up needing treatment plus an unplanned overnight stay for obs for what should have been a same day/outpatient case. As I said before, when I wrote the report, I tried to let it sound as if the resident had been the one to identify the error and I carefully avoided throwing anyone under the bus. Not even the attending who later physically blocked me into a corner so that she could scream at me that, as an ignorant nurse, I couldn't understand the medical reasons for giving a patient a drug to which they'd previously anaphylaxed.

Again I ask... in a situation where there is real threat of harm to patients from ignored safety protocols, how would you prefer that nursing address a situation like this, if not via incident reporting? No one has answered that yet. I really am curious what else you think I should have done. There was no covering up what had happened, so if I didn't write the report, that would have been worse for everyone. I would have been disciplined for failing to report it and a lack of documentation is not a defense if the matter had gone to litigation.

Sounds like you were right to report a system failure, but that sort of write up represents a tiny minority of write ups. Most right ups are just misuse of a reporting system to stab others in the back and often report something that wasn't even wrong.

 

[vector2]

Nope. Sometimes allergies are real. Assuming they are all outgrown or adverse reactions just because so many are is foolish and likely to hurt someone.

The patient was allergic to glycopyrrolate. She'd had anaphylaxis to it after a surgical procedure the year prior. Some of our anesthesiologists provided it routinely as part of their standard inductions, so it was already drawn up and ready to go and no one thought to check that it was removed from the pile of syringes to be administered for that patient. This was a surgery center like environment, where patients were rushed in and out of procedure rooms quickly. PAs and NPs were doing pre-ops, residents and CRNAs were doing hands on, and the anesthesiologist was bouncing between rooms for inductions and extubations. In a situation like that, when people decide to start cutting corners and disregarding time out procedures, it is an invitation for disaster.

When I finally got the chart in my hands (I had to run back to the pre-op area to get it because again, this doctor had a habit of leaving it behind) and started calling out the "time-out" information, the induction was already underway. I got to the glyco allergy just as the resident had started pushing the med. Happily, she didn't get the whole dose. Unfortunately, she did get some, so that she did have a reaction and ended up needing treatment plus an unplanned overnight stay for obs for what should have been a same day/outpatient case. As I said before, when I wrote the report, I tried to let it sound as if the resident had been the one to identify the error and I carefully avoided throwing anyone under the bus. Not even the attending who later physically blocked me into a corner so that she could scream at me that, as an ignorant nurse, I couldn't understand the medical reasons for giving a patient a drug to which they'd previously anaphylaxed.

Again I ask... in a situation where there is real threat of harm to patients from ignored safety protocols, how would you prefer that nursing address a situation like this, if not via incident reporting? No one has answered that yet. I really am curious what else you think I should have done. There was no covering up what had happened, so if I didn't write the report, that would have been worse for everyone. I would have been disciplined for failing to report it and a lack of documentation is not a defense if the matter had gone to litigation.

Just out of curiosity, what reaction did the patient have that you witnessed? What other drugs were administered around the time she got the glyco, both in the past and during your encounter? There has never been a published case report of anaphylaxis to glyco, and even though I still wouldn't have administered the drug, I would've been very skeptical of the initial anaphylaxis claim unless A. the original encounter involved receiving only glycopyrrolate and no other drugs, or B. she had further skin or dose escalation testing done at the time which confirmed glyco as an allergen.

edit: the preservative used in glyco preparations is benzyl alcohol, with which there are reports of allergies. hopefully someone sent this lady to an allergist cause she could theoretically anaphylax if she bought the wrong facewash

 

[Promethean]

Sounds like you were right to report a system failure, but that sort of write up represents a tiny minority of write ups. Most right ups are just misuse of a reporting system to stab others in the back and often report something that wasn't even wrong.

I would argue that they represent a tiny minority of the ones that you hear about.

No one complains about legit write ups. (Well, there was the lady who screamed at me, but she surely didn't do that in front of her peers, who would have taken my side.)

There is confirmation bias, where people hold up obvious egregious abuses of incident reporting but don't also talk about all the other times when they are used appropriately and to the benefit of all concerned.

I would truly welcome suggestions for a system that was less able to be misused. I'm always interested in ways to improve processes.

 

[Promethean]

Just out of curiosity, what reaction did the patient have that you witnessed? What other drugs were administered around the time she got the glyco, both in the past and during your encounter? There has never been a published case report of anaphylaxis to glyco, and even though I still wouldn't have administered the drug, I would've been very skeptical of the initial anaphylaxis claim unless A. the original encounter involved receiving only glycopyrrolate and no other drugs, or B. she had further skin or dose escalation testing done at the time which confirmed glyco as an allergen.

I did expect that someone would want the full case presentation. I can't speak to the full history of this patient, nor can I, several years after the fact, provide all of the details. I do recall that she developed a rash, hypotension, wheezing, and that she was given medications to treat these, plus that I had to make a lot of calls to find a bed for her, since she hadn't been expected to stay. I obviously don't have the chart to confirm that and would prefer not to be discredited on a misremembered technicality, so I won't try to fill in more details than I have.

The point was, her chart stated an allergy to glyco. If our existing safety procedures had been followed, she would not have received any medications until after her name, date of birth, allergies, and procedure had been verified against the chart. The validity of the allergy warning would not have been tested by intentional exposure to the recorded allergen had the chart accompanied her into the room.

As for case reports, they are scanty, but I found a couple without looking past the first few results on Google.

http://www.jddt.in/index.php/jddt/article/viewFile/320/437
http://www.druglib.com/reported-side-effects/glycopyrrolate/reaction_anaphylactic_reaction/

The real error was starting induction without doing the time out. But that happened all the time, and if I wrote it up every time it happened, I'd be one of the nurses that this thread is complaining about. It would be "Why is he making such a big deal of this and wasting our time and getting us in trouble over nothing. Clipboard nurses, I tell ya!" I'd have been filing 3 or 4 reports per day.

This one instance was just the one where doing the unsafe thing (starting before the time out) had a predictable negative consequence (the medication error.)

So, when there are protocols that are in place for good reasons, and they are being ignored by people who think that such measures are nothing but obstructions put up by uppity nurses who enjoy throwing their weight around, what should be done? How can we have safe practice? How can we make the tools better so that they aren't used punitively? These are real, heartfelt questions.

 

[vector2]

tp://www.jddt.in/index.php/jddt/article/viewFile/320/437
http://www.druglib.com/reported-side-effects/glycopyrrolate/reaction_anaphylactic_reaction/

That's usually the problem with using google and not pubmed. In that first link, it's a report of three patients sequentially treated over the course of two days who developed anaphylaxis, and they all received glyco from the same manufacturer and batch. Sounds like obvious bacterial or chemical contamination since the odds of having three true glyco anaphylactic reactions in two days are probably greater than winning the powerball, and I'm kind of baffled why the authors didn't address what was likely the root issue. And that second link does not have any details and is not a case report.

Anyway, I don't think anyone here would disagree with that instance being something that should've been reported (I would've filled out the reporting form myself if I were that resident), and thanks for sharing the case.

 

[psychbender]

The real error was starting induction without doing the time out.

This one instance was just the one where doing the unsafe thing (starting before the time out) had a predictable negative consequence (the medication error.)

This is normal four you guys? I have never worked at a hospital that did a time out before induction, and we don't have a bunch of complications or problems from our "unsafe" practice. The time out is for the surgical procedure, and is performed before incision. These checklists before checklists are just plain ridiculous.

Actually, I take that back, our podiatrists like to time out before induction on their shockwaves for plantar fasciitis or Achilles tendonitis, but that's it.


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[sigrhoillusion]

This is normal four you guys? I have never worked at a hospital that did a time out before induction, and we don't have a bunch of complications or problems from our "unsafe" practice. The time out is for the surgical procedure, and is performed before incision. These checklists before checklists are just plain ridiculous.

Actually, I take that back, our podiatrists like to time out before induction on their shockwaves for plantar fasciitis or Achilles tendonitis, but that's it.


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The new place I work has a billion timeouts and checklists. The surgeon, anesthesiologist, holding nurse and OR nurse (why...?!) has to fill out a specific checklist prior to going back to the OR. Someone inherently forgets to check some box and we can't officially go back which inherently causes a delay. And if you try to bring the patient back early everyone goes nuts... But if a patient arrives a minute past the in room start time, then it gets reported and they have to figure out "what went wrong with the system"! And in the past month or so as a way to prove it's not anesthesia's fault for the delay they want us to sign our patients in 30 minutes prior to the in room time for the first cases of the day. So 7am start gets checked in at 6:30 and 7:30 starts should be signed in by 7am. So what happens is I get in early, see the patient, perform my check in at 6:30am and then twiddle my thumbs for 30 minutes waiting for all the other checklists to get complete and again, inherently something falls through the crack and we get back late. The sad thing is that even if you try to get things done, some of the holding nurses get upset if you start interviewing a patient before they've done their checklist. Such a waste...

 

[Consigliere]

Fair enough. Just throwing it out there. I deal with tons of nurse related stupid bull s h it all the time (especially as a CA3 who has been doing it long enough to call them on their crap but still a resident) so I believe you for sure.


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Ok, so your opinion really doesn't mean anything. As a resident you have to STFU and eat sh_t due to the constant "you'll be fired" hammer your residency director wields. As an attending with many years experience and many, many shi_t sandwiches later, this nonsense gets old. PainDrain, I feel for ya' man. If I could punch these c_unt nurses that you've talked about and get away with it, I would.

 

[psychbender]

The new place I work has a billion timeouts and checklists. The surgeon, anesthesiologist, holding nurse and OR nurse (why...?!) has to fill out a specific checklist prior to going back to the OR. Someone inherently forgets to check some box and we can't officially go back which inherently causes a delay. And if you try to bring the patient back early everyone goes nuts... But if a patient arrives a minute past the in room start time, then it gets reported and they have to figure out "what went wrong with the system"! And in the past month or so as a way to prove it's not anesthesia's fault for the delay they want us to sign our patients in 30 minutes prior to the in room time for the first cases of the day. So 7am start gets checked in at 6:30 and 7:30 starts should be signed in by 7am. So what happens is I get in early, see the patient, perform my check in at 6:30am and then twiddle my thumbs for 30 minutes waiting for all the other checklists to get complete and again, inherently something falls through the crack and we get back late. The sad thing is that even if you try to get things done, some of the holding nurses get upset if you start interviewing a patient before they've done their checklist. Such a waste...

What you're describing is not a time out, though. At my hospital, someone from the surgical team, anesthesia team, and an OR nurse must sign the surgical site verification checklist for each patient (timestamp must be after the surgeon's for dumb reasons). Although, if we all agree that we're ok with verbal, then we can roll back and sign the form later (and back-time the signatures).

One Children's hospital I rotated through in residency had a nifty system. Each person could interview the patient whenever, and electronically check that they were done. When everyone signed, the patient display changed color, notifying everyone that the patient was ready for the OR. When there were delays, it was very easy to show who had not yet signed. When the system was implemented, there was actual evidence to show that the cause of most delays was not, in fact, the anesthesiologists.

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[sigrhoillusion]

What you're describing is not a time out, though. At my hospital, someone from the surgical team, anesthesia team, and an OR nurse must sign the surgical site verification checklist for each patient (timestamp must be after the surgeon's for dumb reasons). Although, if we all agree that we're ok with verbal, then we can roll back and sign the form later (and back-time the signatures).

One Children's hospital I rotated through in residency had a nifty system. Each person could interview the patient whenever, and electronically check that they were done. When everyone signed, the patient display changed color, notifying everyone that the patient was ready for the OR. When there were delays, it was very easy to show who had not yet signed. When the system was implemented, there was actual evidence to show that the cause of most delays was not, in fact, the anesthesiologists.

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I know it's not technically a timeout, but on Epic which we use, it's literally called the timeout box... Once in the room we still have to do a pre-induction timeout, then a surgical timeout and then finally a timeout when the surgery is complete and they are closing up. They don't care as much about teh 30 minute window as they do ensuring the patient is in the room by at least the start time. But they are trialing this 30 minute thing, I'm assuming so they can rub it in administrations face when all the data is collected.