Personal Experience As A Cardiac Monitor Technician
I remember the time when I used to work, as a cardiac monitor technician in the Intensive care unit of a local hospital in Tampa. I was watching the patient’s monitors while one of them started showing and ST elevation on the cardiac rhythm, (ST elevations usually on the strip can mean different things and depending on the leads showing on the screen, it might represent an infarct).
In that case, the patient was experimenting a heart attack. Suddenly, the patient started complaining of shortness of breath and intense chest pressure. I notified the nurse right away what was happening on the monitor, the whole nursing team ran into the patient room. The patient’s blood pressure was sky high, so they administered sublingual nitroglycerin and
morphine. the MD called immediately, after being paged and gave the primary nurse a telephone order.
I clearly remember that the nurse never repeated back, the order to the physician, then she headed to the pyxis (medication dispensing) machine and overwrote the doctor’s order. Finally, she administered a certain amount of Nitroglycerin as a bolus to the patient, a few minutes later the patient’s heart rate started going bradycardic. A pulse rate of 30, 28 and finally asystole. It happened in less than five minutes, so the team resumed CPR (cardiopulmonary resuscitation), by this time the ER physician was in the scene, but unfortunately it was too late. The patient couldn’t survive. The code lasted about 20 minutes.
It was a sad and frustrating situation; when the ER physician verified the patient’s condition, medications and orders, he realized the telephone order received by the nurse was wrong. It was a high dose of nitroglycerin that the patient received and not really what the physician ordered. A miscommunication between the nurse and the medical provider, that could have been avoided. If the hospital protocol had been implemented, such as, “repeat back the order” would have happened. That patient would not have died.
An error in communication is so important, that it can mean the life or death of an innocent individual.
In that case, the patient was experimenting a heart attack. Suddenly, the patient started complaining of shortness of breath and intense chest pressure. I notified the nurse right away what was happening on the monitor, the whole nursing team ran into the patient room. The patient’s blood pressure was sky high, so they administered sublingual nitroglycerin and
morphine. the MD called immediately, after being paged and gave the primary nurse a telephone order.
I clearly remember that the nurse never repeated back, the order to the physician, then she headed to the pyxis (medication dispensing) machine and overwrote the doctor’s order. Finally, she administered a certain amount of Nitroglycerin as a bolus to the patient, a few minutes later the patient’s heart rate started going bradycardic. A pulse rate of 30, 28 and finally asystole. It happened in less than five minutes, so the team resumed CPR (cardiopulmonary resuscitation), by this time the ER physician was in the scene, but unfortunately it was too late. The patient couldn’t survive. The code lasted about 20 minutes.
It was a sad and frustrating situation; when the ER physician verified the patient’s condition, medications and orders, he realized the telephone order received by the nurse was wrong. It was a high dose of nitroglycerin that the patient received and not really what the physician ordered. A miscommunication between the nurse and the medical provider, that could have been avoided. If the hospital protocol had been implemented, such as, “repeat back the order” would have happened. That patient would not have died.
An error in communication is so important, that it can mean the life or death of an innocent individual.