Preventing sentinel events caused by family members
Yolanda M. Hyde PhD, RN, BC, OCN
Donald D. Kautz PhD, RN

$7.95 		Nursing2013 Critical Care
March 2013 
Volume 8  Number 2
Pages 11 - 13
 
  PDF Version Available!

ABSTRACT
The night started as a typical shift. After getting report, the nursing supervisor started to make rounds. For some reason, maybe intuition, the first unit she visited was oncology. As she turned the corner, she saw nurses on the unit frantically working on a patient. As she was getting ready to ask what was happening, she heard the code bell ring and then heard code blue announced overhead. This code was different, however, because it was cancelled before it began. The family decided to change the patient's code status from full code to do not resuscitate. Then, right after the code was stopped, the son approached the physician and asked if his sister could have caused their mother's death. The son and physician returned to the patient's room and discussed what had happened.It was shift change, and the nurses were in report. His mother was receiving a breathing treatment, and the tubing attached to the mask became disconnected. Not wanting to bother the staff, his sister tried several times to reconnect the line. She was having trouble, but she finally was able to reattach the tubing to the line. However, it was the wrong line. She inadvertently attached the oxygen tubing to the peripherally inserted central catheter (PICC). Her brother had sat there and watched this happening. Their mother's condition immediately changed, and nurses were called into the room.Hearing his story, the physician, the staff, and the nursing supervisor went numb. The patient, who had cancer, was stable and projected to go home soon. The medical examiner ruled the patient's death an accident due to air in the PICC, leading to an air embolism. The police were notified, and an investigation was started. The daughter wasn't prosecuted, as the police concurred with the medical examiner that the death was an accident. The nursing supervisor was amazed that the oxygen tubing could be attached to the PICC line, but upon further examination discovered that it was possible.Even though this patient

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