The “Ah Ha” – The Aftermath (Day 2)

What a jammed packed day of emotion! Honestly without prompts it is hard for me to sit down and just begin to write. Except today I was inspired when I was asked by the sweet film crew to record my response to – “What was your Ah Ha moment,”

Through every story I read and watched there is so much emotion; fear, anger, grief. I’ve been in that position as an RN watching something happen KNOWING that I was dealing with the the results of a major medical error.

4 months ago I was called at home by my charge nurse who told me, “Leighann, we need you to come in. We have a rapid response and we need to intubate.” I arrived 20 minutes later, the patient was being settled into her room and I had three doctors at her bedside; hospitalist, pulmonologist and neurosurgeon. The patient was an elderly woman who has went in for a spinal fusion earlier that morning (8am). She arrived to the progressive care unit around 12pm post – op. The patient had never woken up and when mentioned and documented multiple times that the primary doctor (orthopod) has been notified the RN continued on with her day. At shift change, the patient’s condition was handed off to be ‘normal’ and we were ‘just waiting for the anesthesia to ware off.’ During this time the patient has 2 hemovac drains that originated from her surgical site. From surgery they were sanginous and produced very little drainage. Later that evening her output was noted to be 1200ml for 8 hours but it has changed to almost clear fluid.

The patient arrived to my unit with these drains still intact. The patient went down to CT scan after we intubated her for airway protection and we waited. Shortly after the primary doctor, the orthopod, had called the unit asking to speak with me. I discussed with him what was going on and what prompted the rapid response that lead to intubation and transfer. The doctor has asked me to look at her hemovac drains and tell me if there was anything written on them, there wasn’t. Earlier the doctors PA was told to write “do not compress” on the drains. It was never done. Unfortunately, as fate would have it, the patient suffered a dural tear and her CSF has been draining into the hemovacs the entire day.

The aftermath – here is the ah ha moment. The stories that we heard from the families and the actual victims for medical errors are the missing piece at the bedside. I didn’t get to hear what my patient’s family thought about what had occurred or whether they understood what had happened. I do know that she declined rapidly and in a last ditch effort, we upgraded her care sending her to the main hospital where she ultimately died.

Like the puzzles we put together on Day two, we can’t see the whole picture unless all the pieces are put into place. We can’t truly and fully understand the repercussions of medical mistakes until we understand that there are survivors past the error.

I appreciate all of the input and information that was shared today because this is what brought it all home for me.

 

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