A Tragic Oversight: How Misunderstandings and Staffing Shortages Led to a Patient’s Death in the ICU

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  1. An anonymous comment from a friend who works in healthcare, shared with permission:

    It is of course tragic, and of course your points about psychological safety and staffing are on point. That said, the story as told raises other questions that I did not feel were appropriate to post.

    For one, a nurse should never rely on what they hear in shift report concerning DNI/DNI. Patients can (and do) change their mind about their advance directives, and information obtained in a verbal handoff is often inaccurate. Nurses are supposed to review the patient’s EMR to check the most recent physician order re: code status. So it sounds like this nurse did not follow the protocol. I’m not blaming the nurse; as we know human errors almost always have a systemic cause.

    The other part that bothered me is that I picture nobody attending to this dying patient. Maybe you were not given these details, but even if a patient is DNR, as a result of being in palliative or hospice care, that does not mean that comfort measures are not given, a and just left to die. They usually at least get pain medications, the family is called, and the patient is comforted by the care team members, and a chaplain or rabbi if they want one. The nurse and whatever other staff were there should have gathered the team. If they were short of staff a nurse manager should have been called to “float” other critical care nurses if available to cover the patients.

    Again, maybe all this was done, but if not, it begs the question why. New nurses go through a probationary period before being allowed to work independently. How to handle a code for DNR or full code patients should have been covered.

    I am not discounting the distress of this nurse, who deserved consoling, even if she made significant mistakes, nor am I criticizing the blog. You told the right lessons learned from what you were told.

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