Pre-arrival (Breck Session 2): Patient Care Experience Motivates RN to Improve Patient Safety

I am excited for the Telluride Experience in Breckenridge next week! As an RN, I have experienced distress over patient safety on several occasions; some will stick with me forever. I would rather have a “good catch” versus feeling distressed.

The patient care experience that still brings tears to my eyes is one that motivated me to change the way patient information is shared. A patient I had previously cared for as an inpatient had been receiving a newer chemotherapy agent at the outpatient infusion center. He had a suspected infusion reaction; thus, it could not be completed before the infusion center closed for the day. The infusion was paused, and medications were given for symptom management. The infusion was resumed at a slower rate before he was transferred to inpatient. When he arrived to the unit, he was his usual self, smiling and cracking jokes. A lot happened very fast. His platelet count, last checked and stable a day or two prior to receiving his treatment, was critically low the day of treatment and he suffered a hemorrhagic stroke (labs were drawn after I called a code stroke, which is when we knew).

There are things I still think about! I wonder why labs were not checked closer to his actual treatment time. I wonder if I could have caught the event sooner. I wonder if things would have been different if the admitting hospitalist had been familiar with the chemo agent or more comfortable caring for oncology patients. I wish the call list had been up to date, as I tried to reach the patient’s oncologist multiple times when the patient arrived to the unit and then in desperation as the critical events unfolded. The oncologist was listed as on-call for the entire day, which was inaccurate. Like the chain of events Will experienced with his godson in Why Hospitals Should Fly, this was an event multiple system failures/workflow that affected the patient outcome.

After everything, I was just grateful that his wife did not have to experience the event at home, which may have happened if the infusion had been completed outpatient and he had simply returned home. Not long after the event, I developed a report sheet to ensure pertinent information about the patient and the chemo- or biotherapy agent is discussed before admission to inpatient oncology from the outpatient infusion center. Outpatient chemotherapy orders are now visible on the inpatient side (previously they were on paper and we did not even have a copy!). Since this event, the call sheet is (usually) accurate (i.e. stating if a provider is on from 0700-1700 and who is on-call thereafter). It is a start.

The pre-reading has already taught me a lot about ways to make healthcare safer. I anticipate the camp will allow me to share my experiences and learn from others, helping me feel more confident about keeping my patients safe as I enter the FNP role.

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