The one that apparently has become a target for nurses with scissors.
In the olden days when I was trained to be an ICU nurse I was instructed that I was never to go anywhere near the ETT with a pair of scissors. Tapes were tabbed and wrapped in a specific way that they could be unwrapped without dislodging a tube. Back then ETT were re-taped daily, sometimes more and it took two of us – one RN and one RTT to manage the job. The RT was the one who handled the scissors and made the tapes…
Which brings me to now. In the past month I have received three adverse event reports about cut pilot lines. Granted one was actually cut by the patient biting through it, but the other two were cut, intentionally by a nurse. On purpose. Now it is not like this ICU has no RTs to manage the ETT and ventilators – we do. And they are always on the unit. Yet on two occasions, two different nurses decided that cutting the pilot line was the appropriate step to take. No chest assessment for tube placement, no call for help, just cut and then tell someone.
Fortunately in both scenarios the patients survived the nurses’ care and the RT was able to repair the line, but one the patient had to be reintubated because the tube was displaced.
Which brings me to my W.T.F. moment. ICU care is and always has been a team activity. Playing outside the wire makes it unsafe for everyone.
Biggest problem with this is that one of the nurses can’t quite see what the problem is with what she did. I am confounded. Again.