Poor Hand-Off Communication Leads to Jennifer Nibarger's Death
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- Опубліковано 26 січ 2016
- Despite sustaining multiple life-threatening injuries followed by hospital-acquired conditions, Jennifer Nibarger was on the mend until a hand-off communication error between healthcare teams led to unintentional patient harm. Jennifer's husband, Brent Nibarger, shares the tragic story of how a breakdown in communication contributed to his wife's death.
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Wow! What a thoughtful and compassionate man. I'm heartbroken for him and the loss of his wife.
His perspective on how this happened is humbling. He gathered data, learned their system and didn't blame her caretakers. I hope the hospitals learn and implement better systems to prevent this from happening in the future.
I am so sorry. I was an ICU nurse for 35 years. My heart is broken for you.😢
Sorry for your loss. I have been a nurse for 22 years. Cannot believe the decline in healthcare. I do not provide patient care anymore. I refuse to take 10 to 12 patients and think I can provide good care. Not possible.
Thank god someone said something
Same here
Unfortunately now, any one of the nurses involved in her care can potentially find themselves in jail. Nevermind that one of the major causes of this tragic case is a hard to use, expensive, electronic medical record. I'm sure the hospital would gladly throw one the nurses under the bus and not take responsibility for their system failure. From a great resignation nurse.
I agree with you Nico, I refuse to take on more than 5 patients assignment, it’s simply not safe !
After 30 years I’m so so glad I got out of hospital nursing. the last five years with the electronic medical records and more technology with heavy micromanaging really took me away from the patients in a very bad way. having to chart on the computer is very distracting and Frustrating
Cannot imagine the pain and grief of this brother....praying for you
Maybe if nurses didnt have to waste so much time charting. Too understaffed and toooooo many patients
I was born with spina bifida and at 40yrs old I've had 21 surgeries and about to have #22. I have a hip replacement, knee replacement, metal plate in my neck, and 5 titanium screws in a fused ankle. Those are just the hardware surgeries. With being a career patient I have seen many things within our healthcare system. I have come to taking a famous quote from president Eisenhower and changing it for our healthcare. Healthcare has become "the medical industrial complex". Healthcare has become a business over actual health! It has become so fragmented where a lot of the time the left hand doesn't know what the right hand is doing. Also, I have seen a huge decline of how patients are treated. A patient is almost seen more as a commodity than a person. This fragmented system is a way for plausible deniability, and if something goes wrong there are so many hands involved that its difficult to pin down who's at fault. This is done on purpose!
Thank you for sharing - articulate - precise. It is time for a revolution in health care information flow.
Nurses now are doing mostly things that are done by certified nursing assistant rather than focusing on clinical and biological issue that could generate potential harm. Hospitals mostly put in less help to save budget. Relatives on the bedside likes their patient squeaky clean. You may do all your best correcting and prioritizing clinically important conditions but yet in their eyes you are negligent when their patient is unhappy and dirty. Most hospital now also focuses on making the numbers for outside rating agencies and government reimbursements. Such that nurses time is 50% just filling in data on medical record to satisfy these agencies. Nurses also is a slave to time set by support services such as imaging department. We have to get there in time to have our patients scanned,etc. And as usual when shit happens the nurse is the first one to get blamed. Time in time again I always say that the job of the nurse is to safeguard patient safety by being the advocate as well as the eyes and ears and brain of the treating clinicians. Most reports/handoffs really lack analysis from handing off nurse that oftentimes you don’t get the big picture unless you take time to read the charts, process and analyze data to see threats to your patients as well as opportunity for improvement. Meantime while your receiving hand off or report, ER is calling you for a new patient and patient wants to get cleaned or suctioned and CT scan probably wants you to bring patient ASAP otherwise get bumped. True this events should not happen to anyone but it does.
Sigh!!!!
@Amy Weinholtz I hate when they do this. They wait last minute.
Those care givers failed you and your dear wife. How utterly shattering. They should answer for their negligible actions that resulted in the death of your loved one.
I’ve noticed how many people in the medical world have quit and even suicided after the pandemic and what Whitney wrote is the major complaint I’ve noticed.
Too many patients and not enough time to help everyone.
I'm so sorry for your loss.
So sorry for your loss.
My sympathies... I can sense the love you had for her. Did they perform CPR right after they found the TEF; in other words did the barium entering the lungs cause the arrest?
I think it’s a combo of the barium going into the lungs and hypoxemia which is
low oxygenation levels causing her to crash. When they were providing rescue breaths with the ambu bag the oxygen was going through the fistula or hole in the trachea to the esophagus and into the stomach. I was an RT for many years. This hole was most likely caused by the balloon near the bottom of the trach. If the balloon is inflated too much it can rub against the trachea and eventually lead to the hole in the trachea which allows food and oxygen to cross cross into the wrong “pipe”. That’s the best way of explaining this. Major screw up.
She essentially drown from the barium in her lungs 😢
Omg I'm so sorry this is horrible
Whether they knew or not, they SHOULD have known. It's unacceptable. I am so sorry for your loss.
How ? They don’t have xray vision , they arent miracle workers. It unfortunately is an acceptable loss. There is not always someone to blame.
I did a 54 page paper for a university in my MSN. Program on safe patient handoff. I can’t get my hospital admins to read it.
Beyond WTF!!!
Wow!!! Shame on them!
Negligence…they should know! No excuse sue everyone involved
@@PatientSafetyMovement very mature response
@@PatientSafetyMovement sometimes improving the system means holding responsible people (often people at the top) accountable, though.
Patient Safety Movement
I’ve noticed that the only way doctors and hospitals implement change, is after being sued by family members.
I don’t understand how many people missed something that seems like it should be obvious to anyone who had any medical training?
sadly we have seen this kind of thing occur many times, EMR ( often selected by bureaucrats with no feeling for the complexity of the medical world ) are often hard to use, waste doctors time, and do not lend themselves to personalisation, or giving , perspective, for example, I can not write the main problems in big letters or underline in red. Prescribing medications and making changes to IV fluid orders can also be a nightmare. Paper based files should still be used, they can be integrated with EMR.
I worked in a hospital as an aide while in nursing school, we printed all patient records yet none of the RN’s spent time reading about patients on our floor. The ugly truth is the RN’s spent any free time gossiping about other employees, making fun of patients and their families, watching videos on their phones or hiding in the med room. I would report to my assigned RN that a patient was complaining of high pain level yet it took an unreasonable (cruel) amount of time for the RN to respond because their priority was socializing with co-workers. I was so disheartened by my observations that I chose to not become an RN. Our healthcare system in USA is completely broken and filled with people who have NO business being practitioners. Sure, many excellent providers are out there still working, but the lion’s share should not be responsible for caring for people.
@@86corruption 100% girl you tell em! I'm leaving nursing because of the gossip, backstabbing, and fuckery that goes on. It's like The Mean Girls and Heathers got together, joined forces, and made their own film. The staff drama is off the effing chain.
No one ever talks to the patient in a hospital when there is a mistake: it is made their fault.
Wow she reached so far and then died
Do they not use ANY paper records any more = nothing over the bed or on the end of it or written LOUD somewhere? What if systems/computers went down?
I don't buy that 'they didn't know' that most serious injury that compromised her airway: THAT should have informed everything & should have been HIGHLIGHTED big & loud plus included AGAIN with everything else; that it doesn't appear on the version of the electronic medical records he was given is not evidence that 'they didn't know' or that that information was not also elsewhere within these records at some time (& later removed = my medical records were falsified by the guilty docs/hospital) = unless you've been given unadulterated (& how do we KNOW?!) audit trails = that information MUST have been flagged up, to not do so would be gross negligence (maybe criminal), obviously.
So sorry for this sad story = yes: handovers are (can be) a VERY weak link in the chain & must be improved. Repeated ('lost' or many/most/all probably were never in my WRITTEN records in 2005 & medics don't write down their own/others' errors) handovers were a big problem in my own case: docs/nurses didn't write up their errors & nobody believed me or asked me ANYTHING after: terribly shoddy & shocking = the NHS in the UK.
It's pretty much all computerized now. And look at what happened with that Vaught trial. The computers aren't setup correctly or the staff doesn't know how to properly use them. It's a mess with very little regulation.
@@AlcideIzMine Don'y know what Vaught trial is/was. Very dodgy ONLY on computers I think: hacking, corrupted, wiped, viruses, back-ups/storage & new systems = transfers etc. People in the future will laugh at us in our computer infancy right now...
@@jennyhughes4474 The Vaught trial was over a nurse who accidentally gave a paralytic to a patient and they died. Part of her defense was that the computers weren't working properly and that she was trained wrong on how to use them anyway. She also didn't have a scanner available to scan in the drug, which would have alerted her to the error.
If she had just looked at the vial, though, she would've seen it was the wrong drug. She was relying solely on computers that apparently weren't operating "correctly".
The hospital should've had the computers setup correctly. Trained staff on how to use them. And taught the nurses not just rely on the computers.
@@AlcideIzMine Yes, thanks. In my own case in 2005 there was a terribly shocking & dangerous lack of correct training & very basic common sense amongst several medics who were responsible for my health and my life; if I hadn't witnessed it all myself I probably wouldn't have believed it was possible that so many were so incompetent and utterly stupid - in a large NHS teaching hospital in England; it was a weekend and I've since read that loads more patients are harmed then because there are no senior staff & consultants around (only 'on call' at home) - I really hope this has changed.
Too much reliance on computer systems is very dangerous. My misdiagnosis began with a rubbish NHS computer programme operated (I think) by non-medics I'd rung for advice after suffering food poisoning/runs in the night. This very badly written/designed PC programme silently, without anyone telling me, changed what I knew was the cause (bad supermarket ready meal - had left some because it didn't taste right) into appendicitis; any medic with any common sense would have seen me wandering around bored in hospital, not complaining of pain or feeling sick and clearly not unwell. Long story but they all appeared to have blinkers on & unable to actually see & think = truly shocking and very dangerous - the medics were trusted to care for & diagnose patients and showed time & again they were unable to do their basic tasks.
Computer systems are only as good as the hardware, software and connectivity and medics must be able to cope without them at all times. I sincerely hope my case and so many others will alert all to how easily patients can be and are harmed; if medics admitted immediately then learning and preventions could be put in place - and real true data gathered, but in my case and so many others medics immediately go into lie, deny, cover-up, fake the med records and then, worst of all, wilfully & maliciously neglect patients injuries they know they have caused - they did this to me knowing that I might die, but they only cared about themselves so carried on lying because they mostly get away with doing this and are never held accountable - they must be..
Skip this music next time, it's not Hollywood.
The boat wreck was what really caused her eventual death. I would like to know more about the crash.
you’re a sick person. Go to hell
wow you are so wrong!
It’s true! It all started with the boat wreck…if it wasn’t for the wreck, she wouldn’t have been in the hospital.
@@quelquun2018 uh it may hav started with the boat wreck but in the end it was negligence by the staff. She was on the verge of going home. All she had to do is pass the barium swallow study. The hole was most likely caused by the cuff at the end of the trach tube in her trachea. It had too much air in it which made the cuff too inflated which meant that the cuff was rubbing up against the trachea and eventually causing the hole. Because of that hole any food or in this case the barium could cross from the esophagus to the trachea and the oxygen being pumped into her was crossing over to the stomach. Between those two events it caused her death. They needed to repair that hole immediately before allowing her to eat or drink like the barium. This was not caused by the accident. It was caused by the cuff of the trach tube. It’s common knowledge that that can happen among RT’s and doctors. That’s why we always checked the cuff several times per day. This was in part negligence
Yes why do a barium swallow if you suspect a hole in the esophagus to the trachea? for heaven sake where did they think that barium was going to go or were they counting on the test being negative? Either way it’s negligence on the part of the staff.