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October 1996

Survey on Incident Prevention Results

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One day while helping nurses aids feed nursing home residents their dinner,I saw that the aids were about to give the residents milk that was nine days past the experation date.
Posted by cmaley
Saturday, March 26, 2011 at 15:23:23 (EDT), IP Address: 2410216546
Maybe they need counseling, maybe they are stressed out or something. Do you have EAP (Employee assistance program) in your organization? Many organizations are giving stress management lectures to their patients and staff. Hopefully they will get some help. Hopefully your supervisors and colleagues will become less stressed out themselves and become more focused on taking care of themselves and patient care.
Saturday, June 01, 2002 at 08:33:13 (CDT)
There is alot of nepotism in my department. We have an administrator who seems blind to substance use among employees. We have two alcoholic/substance use therapists.The TR department thinks their behavior is cute their use and abuse. Patients who they treat know that they are abusing and have reported them to the Board of Health.As one who is morally and ethnically obligated to NCTRS standards and my own have annonomously reported them to our agencies ethics committee. The sad thing about this is that the ethics committee is defunct and the therapists continue to come in drunk or high. Their behavior is both abusive and manipulative toward patients and staff. One therapist seems so out of control into everyones personal business most of the day. It is amazing how administration can be blind to this. I have taken it annonomously to higher authories for fear of retribution. Patients sadly enough to say are so at risk.
Wednesday, May 29, 2002 at 17:45:52 (CDT)
I do all of our community re-entry programs. We are fortunate to have our own 19 passenger bus with a w/c lift, but unfortunately it is not the most reliable. I had taken my patients to a late movie, and was going back to the facility at about 10:30 p.m. on a Sunday night when the bus broke down. We were broke down on the interstate with cars whizzing by, and being so late at night it was really scary. I got out our flares and attempted to flag down some assistance. On of my patients with a, head injury, proceeded to "help" me, by trying to flag down help in the middle of the interstate! He used to be a "junior policeman" and he felt as though me knew what he was doing. After many attempts to redirect this patient and get him off the road, I had to resort to getting in his face and telling him how things were going to happen! Fortunately he responded reluctantly... We were very lucky that a man and his wife in a conversion van stopped and loaded myself and 9 other patients into their van and took us back to the facility. Out of this experience, I insisted on getting a cellular phone for the bus, and this has helped somewhat in alleviating the anxiety of taking our unreliable vehicle. And believe it or not... after 2 years we are now getting a brand new 1997 bus!! yeah... It should be here in January.

Happy Outings!!!

I have been struck several times by people with dementia when trying to intervene and prevent additional problems or injuries to others. The best thing to do is to walk away if you can't get anywhere, possibly try to reapproach, or have another staff member approach.

A camper drowned while swimming in a lake with close supervision from a WSI. Patient had a cerebral hemorrhage in the water and died. Could have happened on land. Problem was, we had no procedure for dealing with such an emergency and most staff were quite young and wanted to panic. I learned that you can never tell when such a thing will happen, but you should have at least thought about what would happen in that case.

Gosh, I've had my share of incidents.......runaways always make you feel bad. One adolescent ran away and of course the police got him several days later and he had pierced his eyebrow and got a tattoo while on the run. Another adult runaway...was court ordered and we had to notify 3 counties that he had escaped.

Wrecking the hospital van is another minor incident. Only 2 people went to the emergency room....the van was unharmed (bumper to bumper wreck). The moral of the story....always have every patient in the vehicle wearing their seatbelt. We now have signs posted and pretty much say..buckle up and check to make sure they are buckled. Believe it or not....patients will say they are buckled when they aren't. Of course, these are the patients that complain about being treated like babies. The incident was very stressful and much paper work to do.

We also have started to never take a patient out even on the grounds 1:1, male and male staff or male and female staff or vice versa. Psych. patients can make up the most believable stories about abuse by staff members.

My advice: always have the doctor's order to take patients out, take additional staff with you, buckle up and check, keep together in a group, and of course, have FUN!!

OK, this is funny but it really isn't.... I had a group of adolescents on an night hike and we build a campfire and roasted marshmallows. You know how some people blow out the marshmallow when it catches on fire and how others kind of shake the stick back and forth. Well this one teen shook his back and forth a little too hard and the burning marshmallow flew backwards about ten feet back and HIT another kid in the eye. Needless to say, that kid got a slight burn around his eyes. Trying to explain what happened to staff and on the incident report form was not easy. I guess we all have to be careful and be aware of UNEXPECTED incidents in order to make it EXPECTED and take all precautions not to let it happens.

Once, I took a young man with Cerebral Palsy and a 14 year old boy on a row boat on a small lake. I placed the client in the middle of the boat with myself rowing. After a while, the client asked if he could try rowing. I agreed. Unfortunately, as the client began to row, the boat when in circles. As I attempted to show him rowing techniques, he pulled on the oars too hard, lost balance, and began to fall out of the boat. I grabbed him by the back of his shirt. His head was under water and the boat was dangerously leaning over. Fortunately, the boy that was with us leaned the other way and kept us from turning over. With all my strength, I was able to bring the client back on board. He was wearing a life vest but it would have been difficult to get him back on board if he went completely overboard or over-turned the boat. What did I learn? I was a young therapist at the time and hadn't been taught much about risk management. I've learned that I need to assess every activity, even if its Tidily Winks (a young client can swallow it right!?) for risk factors.

I encourage other staff and helpers that if they feel unsafe, then it is unsafe and they need to speak up loudly if its a safety issue. I warn clients of all risk factors prior to starting any activity. I place responsibility for safety onto each client as well as myself and other staff. Safety is no joke.




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