As a ICU RN for ten years in the adult cardiothoracic intensive care unit and in the neonatal intensive care unit, I will never forget the stories of my patients. Most shifts as an RN are demanding. Within 12 hours, there are daily routines for patient care along with recovering postoperative patients, managing complications, transferring patients, procedures, and new admissions. In this short period of time, we are at the front lines of patient care and we must not miss anything. Being a bedside nurse is more than just tasks and following physician orders, it takes compassion and diligence. It requires open communication with multidisplinary staff and developing a trusting relationship with patients, despite our differences in background. Attending the Telluride Experience is important to me because patient safety is critical for improving health outcomes.

During an admission of 30 week twins, twin B was delivered with signs of respiratory distress and hypoxic ischemic enchephalopathy. During the first 24 hours, the infant was stabilized with intubation, intravenous fluid boluses, and central line placements for monitoring. During the next 48 hour period, there was no improvement. As a bedside nurse, I saw small changes in her tone, color, and hemodynamic stability. My concerns were for seizures and disseminated intravascular hemorrhage. After a capillary blood draw, I called for the attending to be at the bedside. I expressed my concerns and was criticized for overreacting. He yelled at me to look at the monitors because they did not indicate seizure activity. Yet, the infant was apneic and unresponsive.

After a capillary blood gas, the results indicated a metabolic acidosis with partial respiratory compensation. The neonatologist took a picture of the cerebral function monitoring and sent it to a consulting neurologist. My suspician for seizures was confirmed. In addition, my heel stick continued to bleed despite 30 minutes of manual pressure. I begged the physician for a coagulation panel. The results showed disseminated intravascular hemorrhage. The infant received platelets, FFPs, and PRBCs.

With the resolution of coagulopathy, further diagnostic studies showed the infant had severe hypoxic encephalopathy and a hepatoblastoma.

A patient safety report was completed but there was no feedback, With the support of my nursing peers and nurse manager, we organized a debriefing with the physician and the director of neonatal medicine. Sadly to say, the physician did not attend the meeting and nothing has changed.

Unforunately, this scenario is common. But, more must be done. As a DNP student, my goal is to become a leader in patient safety. I truly believe that we must not forget the stories of our patients and that we must do more to protect them. I will never forget these twins, their mother, and helping the father hold them together for the first time.