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Feature: SHARING

An alarming patient safety concern

Aul, Karen PhD, RN, CNE, CHSE

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doi: 10.1097/01.NURSE.0000823244.90613.bb
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In Brief

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Early in my nursing career, I began working as a nursing supervisor in a long-term-care facility. After completing an uneventful orientation to this new supervisory role, I thought to myself, “How hard could this be?” I felt confident in my nursing skills and clinical reasoning despite being a nurse for only a few years. However, my skills were soon challenged.

One day just as I was preparing to leave work and looking forward to having a quiet weekend, I heard my name being paged on the overhead intercom system. As I answered the page, a nurse came running down the hall shrieking, “He's missing!” As a nurse, I had learned quickly to always remain calm. So, with a gentle voice, I asked her, “Who's missing?” With panic in her eyes, she yelled, “Mr. Johns is missing!”

I knew Mr. Johns as a 75-year-old resident in the memory care unit. He had a history of dementia and often showed challenging behaviors. His plan of care included strategies to support his safety because he tends to wander frequently. I asked the nurse for more information: “Have you checked all over the unit? Did he wander into another resident's room?” By this time, she had started to calm down enough to have a conversation. “We have checked all over the unit and all of the rooms, and he is nowhere to be found!” she said.

I knew there were alarms on all the doors and Mr. Johns had an alarm bracelet that would have sounded if he tried to leave the memory care unit, but I asked anyway, “Did he leave the unit?” She retorted, “No alarms have gone off,” to which I replied, “Are all of the door and bracelet alarms working?”

Before the nurse could answer, I heard a nearby patient-care assistant yelling and pointing out the window, “There he is! There he is!” I ran to the window, and, to my dismay, saw Mr. Johns was slowly walking down the highway about two blocks away from the facility. I felt my heart skip a few beats as I raced for the door. I sprinted as fast as I could to where he was, praying along the way. The air was cool and crisp, but not having a jacket on was the least of my worries. The cars were whizzing by me along the highway. I muttered to myself, “Please don't let Mr. Johns get hit by a car.” I envisioned a bad outcome for the resident and for myself. I felt my nursing career going up in flames.

My chest hurt from running so fast with the cool air flapping against my uniform. Finally, I caught up with him and said, “Mr. Johns, I am here to help you back to your room.” He winced and whispered, “I can't find my room.” I reached for his arm and we slowly walked back down the highway toward the facility. We made it back safely, and I escorted Mr. Johns to his room. The staff was relieved to see Mr. Johns was okay and helped me get him settled in his recliner chair for an afternoon nap. I then investigated how this happened.

The door and bracelet alarms turned out to be malfunctioning. I immediately took the proper steps to report and resolve the issue.

I am grateful that no injuries were incurred in this incident. Throughout my nursing career, I have always kept this experience in my mind when caring for patients with dementia. I think about how patients can present risks to their own safety as well as the safety of the staff. Even though I just started working at this facility, I trusted that the staff was dedicated to providing excellent care for the residents who were like family. This experience undoubtedly shows that it takes a team to keep us all safe.

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