***Based on some real stuff that happened but we’ve changed the names***
New staff member; First day on the floor after facility orientation. She’s getting vital signs on her group of patients before she starts her other duties. For Mr. Johnnie Blaze, she documents a pulse ox of 69% on 2L via nasal cannula……..
Yeah, you read that right! 69% That’s nearly dead. What would you do in this situation? Better yet, what would you as a preceptor expect the new staff member to have done in this situation?
Well let me tell you what happened.
Upon documenting this pulse ox of 69%, the staff member moved on to get vitals on her remaining patients.
Consequently, Mr. Johnnie Blaze was found an hour later with absence of pulse, respiration, and blood pressure. A code blue was initiated and was successful, however, he was declared what we call ‘brain dead.’ His life sustaining treatments were discontinued a few days after the incident.
Why did this happen?
It all came down to an assumption. It was assumed that because this staff member had been in the field for over 25 years, that she would have known. This assumption also led to the decision to allow this new employee to provide care-on day one-without preceptor supervision or better yet, guidance. This assumption led them to forgo an accurate assessment of this person’s skills and abilities as required by most accrediting bodies.
It was later discovered that the 20 something years’ experience of this person was spent entirely in the hospice setting and that this staff member had rarely if ever obtained a pulse ox, and if she had, it was nothing meaningful to her as the point of her experience was to help others pass on peacefully.
This is why the role of the preceptor is so important. A preceptor could have asked critical questions, offered direction, and potentially prevented this tragic outcome.
Key Lessons for Preceptors and Nurse Leaders
- Assess Skills, Don’t Assume Them: Just because a nurse has years of experience doesn’t mean they’re proficient in a new care setting.
- Prioritize Preceptorship: Regardless of experience, new staff members need guidance and mentorship to navigate unfamiliar environments.
- Foster a Culture of Continuous Learning: Create an atmosphere where nurses feel comfortable asking questions, even when they’ve been in the field for decades.
Sound off
Knowing what you know now about why this happened, what’s your conclusion? Does her lack of experience with people who aren’t dying excuse what happened? Did the unit fail to adequately assess and train this individual? Should she have known better? Leave your comment below, let’s discuss it.