OK so we all agree that if nothing else then this represents a monufeckingmental FAIL somewhere along the line.
Certainly does. My experience of this sort of thing is that its multiple small failures leads to one almighty foul up.
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This nurse turning off the life support system story
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Posted 1 year ago #
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How many people go through life can say they have never made a mistake or had poor judgement? Not many, and none that are honest.
It just so happens that people that work in healthcare situations are the goalkeepers of the world. I.e. when they make mistakes people tend to notice.
Posted 1 year ago # -
I wonder what "Turned off at mains by mistake" scored on the DFMEA ?
Do these things not have some kind of protection against this ?
Even Windows asks if your sure you want to shut-down.Posted 1 year ago # -
Ms Aylward has been suspended while the incident is investigated by the Nursing and Midwifery Council.
No surprises there...
all this happened in january 2009 though... ambition 24 is still going strong
I think the NMC might have dealt with this nurse, as a quick search on http://www.nmc.org.uk doesn't show anyone with her name on a nursing register in this country.
Corners get cut, people get slack, mistakes happen & people die.
I'm not making light of the situation, far from it, I spend a far too significant portion of my working time chasing medics who have prescribed drugs incorrectly and then the nurses who adminstered the drug of an incorrect prescription - neither medic or nurse sometimes understands what they have done wrong, and their re-education therefore falls to me.
Posted 1 year ago # -
I must say that this horrifies me.
A few of the nurses I work with do agency work, but I'm happy that they have the experience and insight to deal with that situation, as I would have had.
This is someone without the experience and/or knowledge and/or skill being sent to provide nursing care to someone whose LIFE depends on the ability to use a ventilator or to hand ventilate if that vent fails.
I have had occasion in the past to take a nurse off to one side and suggest that she didn't have enough experience to go and do agency work of this kind; she didn't like me for saying it, but she understood why I did and didn't go ahead.
The agency should get hammered, the nurse should be struck off, the directors of the agency should not be allowed to work anywhere near healthcare ever again.
...and the NMC should have a word with themselves; they talk such bollocks about nurse registration and their role in patient safety; didn't work, did it?
Posted 1 year ago # -
Crikey - I tend to agree with you that it is a horrific failure. I don't like the "hang the nurse" ethos. Its hard to know why this situation happened but I would bet that blame is actually spread quite widely - from the nurse to the directors of the HA.
Its too easy to say theat the nurse was culpable for working beyond her expoerience but we don't know the situation or the pressure she was under.
Posted 1 year ago # -
Posted 1 year ago #
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I don't like the idea that the nurse is individually responsible, but the whole idea of registration and training comes down to the actions of an individual, and she messed up massively.
This may have been as a result of a system failure, but that is not an excuse.
A cursory look through the NMC site reveals the many and varied ways that nurses cock up; this is a serious incident and will probably result in her losing her registration.
She should then be able to sue the agency, but that single point cock up is hers I'm afraid.
I have spent shifts at work, 12 hour shifts, trying to watch 3 or 4 brand new fresh out of training nurses on Intensive Care. You know that it takes 1-2 even 3 years of training and experience to become a good, safe ITU nurse. On those days, I don't take breaks, I eat standing up at the nurses station, I check everything, and then check it again.
The whole thing makes me mad; I'll spend the next 6 months answering questions from relatives about this....
Posted 1 year ago # -
I don't take breaks, I eat standing up
You eat? How very dare you! Need I remind you that the comfortably-ensconced public sector must take their share of the pain.
As to the NMC: I take a rather dim view of their pronouncements on safety, and the same goes for much of the platitudes from the senior Nursing hierarchy. As a student nurse, I was pretty dismayed to find that the ongoing decrease in medical cover was welcomed by several nurse lecturers as some kind of glorious opportunity for "nurse empowerment". Though I note that they aren't the ones staffing general wards on a friday night.
Posted 1 year ago # -
Don't get me wrong - I am merely trying to point out that for the nurse to be in the situation where she can make the mistake there almost certainly will have been a series of other failings - from the commissioning HA to the line manager in the agency to the politicians who decided contracting out services on the basis cheapest is best is a good idea.
I have some sympathy for the nurse as I was put in a very difficult position similar to this by a combination of over eager agency and incompetent NHS management.
Posted 1 year ago # -
I agree that for her to be put in that situation is inexcusable, but I would equally agree that she shouldn't have done anything at all if she wasn't sure and competent.
No doubt she will get hammered and those who should have had systems and checks in place will get a wee slap on the wrist.
Annoyed now...
Posted 1 year ago # -
I've worked for agencies doing ITU work as well as home ventilation.
There definately is (or was) a pressure to "get on with it".
Although well trained, i did come across vents that i hadn't used before and so always asked the previous nurse for a crash course (not totally desirable, but often unavoidable).
You do need a fair bit of confidance to speak out and say, "I don't know this etc", "i'm not happy etc"I understand TJs point of a blameless culture achieving better results, but i know that will stick in the throat of the family who know that without mistakes or negligance, their family member would be unhurt, and rightly or wrongly want blame assigned.
I read the link to the edinburgh case, very sad. Mistakes were made on many levels and lessons were learned and better practace implemented.
As sad as it is, our health care is as safe as it is due to lessons learned from harm/death occuring from mistakes.So, certainley a full and fair investigation needs to be conducted but blame is rarely simple.
Posted 1 year ago # -
2wheels - actually I have seen research to suggest that families don't want someone blamed. They want to know what happened and want an apology and to be reassured it will not happen again.
Posted 1 year ago # -
I feel sorry for the lady if she was a qualified nurse , she has been plastered over all the news channels, as the person who switched off the power, and didnt know how to resusitate the chap.
Thats due to poor training and very poor management by the health authority and the private sector, she should have rung for paramedics straight away,or there should have been an emergency sheet to folow.
SHE GOT CAUGHT HOW MANY DONT GET CAUGHT and the system covers up for them.
Oh and the chaops care package cost £450,000 per year, according to the early news.Now thats a lot of our taxpayers cash.
Posted 1 year ago # -
TandemJeremy - Member
2wheels - actually I have seen research to suggest that families don't want someone blamed. They want to know what happened and want an apology and to be reassured it will not happen again.Posted 19 minutes ago # Report-Post
From very personal experience, thats what i wanted, strangely people in the know decided to lie and try to alter the facts, only through the freedom of information act did i find out the truth,and 2 muppets resigned for being incompetent in their jobs.
Sadly the senior management didnt learn the lessons .
Posted 1 year ago # -
Everyone involved needs their bottoms kicked very hard. No excuses.
I spent 3 weeks in SCBU with our baby and found mistakes almost daily with the care of our child, some of which have made the first year of his life far more difficult than it should have been.
There are no excuses in any job for carrying it out poorly, if you dont like the pay or conditions dont hide behind them. Go and stack shelves or move to a country where (you think) everything is better.
Time to clear the UK of the apathetic, lazy, greedy, ignorant people.
Posted 1 year ago # -
It's likely that it is paid from some insurance settlement, although some people do end up getting this level of care on the NHS.
I would agree with the idea of being open and honest; it should never take the place of a fair and equitable financial settlement, but we owe it to people to say exactly what happened, and to learn real, demonstrable, sensible lessons from every incident, and to be able show that we have changed practice in order to prevent any repeat.
Posted 1 year ago # -
You do need a fair bit of confidance to speak out and say, "I don't know this etc", "i'm not happy etc"
Is it not your duty under your professional codes of conduct to point this out?
Posted 1 year ago # -
What project experienced is exactly why I want to see no blame investigations. You would still be able to make sanctions against people but only in exceptional circumstances.
Posted 1 year ago # -
I have spent shifts at work, 12 hour shifts, trying to watch 3 or 4 brand new fresh out of training nurses on Intensive Care. You know that it takes 1-2 even 3 years of training and experience to become a good, safe ITU nurse. On those days, I don't take breaks, I eat standing up at the nurses station, I check everything, and then check it again
I bet management love you, "How's ITU?"
You: "Fine, I've broken my personal record, I've not had a decent meal break now in 9 months, the unit can't survive without me"
Manager "Splendid, keep it up".
To be blunt, when you're gone, you'll be forgotten about in 6 months, if that. After 22 years in nursing and the last 18 months of serious personal illness, then it is life & family first, my 37.5 hours second, up to that I was a silly hours person being led by an even sillier hours person who couldn't see she had no quality of life. No one nurse is indespensible. No patients were harmed during the typing of this post, I am on annual leave this week.
Posted 1 year ago # -
No one nurse is indespensible.
I agree, and I wasn't trying to come across all supernurse
I also agree with the 37.5 hours thing. I do take it seriously though, and while I'm there I work as hard as the job demands, and that means making sure the people I'm responsible for, both patients and nurses, get as good a service as I can give.
As for being forgotten; I don't do it to become a legend!
Posted 1 year ago #
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