case analysis on clinical incident

7/31/2019 Case Analysis on Clinical Incident

1/8

Page 36

CASE ANALYSIS: CLINICAL INCIDENT

A. PATIENTS SAFETYB. INVOLVEMENT OF COLLEAGUEC. INVOLVEMENT OF MANAGEMENT


2/8


3/8


4/8

Page 39

B. INVOLVEMENT OF COLLEAGUETHE SITUATION:

NURSE:I committed this medication error during my first month of training in the

hospital. I was assigned in the medical/surgical/pediatric floor of the hospital.We have 38 patients at that time and we're only 4 nurses on duty, dengue

hemorrhagic fever was on its peak...so in short, it was a toxic duty. I was

assigned at that time to do vital signs and another nurse was assigned to do themedication. There was a new doctor's order for one of our patient which was to

incorporate BNC or benutrex c. I was not able to read the doctor's order andwas not assigned to do the medication. The nurse assigned to it, prepared the

medication and asked me to give it to the patient without any instruction, shejust said gives it to the patient. I was looking for the medication card and shesaid there's none for such order. So without hesitation, I gave the medication but

I gave it via IV push. The patient reacted when the medication hit her vein

because she said it hurt a little so when I returned to the nurse station, I told myhead nurse, "The patient got hurt a little when I gave the meds" so she askedwhy. I said "I IV pushed the meds" and it all started there.

My head nurse called up the Supervisor to report the incident. When I was sonervous that something bad might happen to the patient since I gave it

incorrectly. So what I did was to monitor her every 15 minutes to make surenothing bad happened to the patient and even checked if she's developing

allergies although it was given after negative skin test reading. I got so worriedduring the entire shift and I asked myself, why did I do that...I promised myself to

never ever give medication that I did not prepare. I took accountability for thatmistake and even volunteered that I will make an incident report.

The hospital that I work with is a small tertiary hospital with only a few employees,so rumor spreads so fast that this new nurse made an error. I was not aware that

there was a young nurse who's working in the hospital longer than me, who wereirritated the way I speak...in short, she dislikes me because I'm too feminine and

she even quoted me as their "favorite" in their unit, in a sarcastic way. I wasthinking, what made her to dislike me since I was not able to work with her

during shifts. She was in night shift and I was in the morning shift. She does notknow how I do my work and on how I treat other people. She does not know me

so well for them to judge me. She said negative things about me; she even gave

me a name "BNC". She even told new nurses about my error with my name inthe story then they made fun of it, making me and like a stupid nurse. I've been

hearing those things, it hurts, it lowered my self-esteem and even felt so

demoralized but I let things roll off my back.


5/8

Page 40

Just a few weeks ago (I've been working in the hospital for almost a year now) Iheard negative things from her again; she wanted to hit me in the face

because she got irritated the way I look at her. I said to myself, I don't do

anything bad to her, she does not even know me and I don't deserve what she's

doing to me, I have to stand up for myself. I've been keeping my patience formonths and this time she went overboard. I went to their nurse station andconfronted her; I can say I made a scene out there. It was not my intention, but

this nurse told me that I was rude so the conversation ended up with loud

voices.

After the incident, this nurse that I confronted talked to our Supervisor about it; I

voluntarily made my incident report to explain my side about it, why I got mad.

We ended up having a resolution with our Nursing Service Director. I told her

everything, the nurse I confronted had the guts to deny it, and she even told the

director that she does not know why I was angry at her. But when I voiced out

what's inside me, she was caught because she told the Director that she was

not the only one laughing but everybody. The director told her that medication

error is not a laughing matter but a delicate issue because it can be fatal. In

front of the Director, we reconciled but I know outside the director's office I

know, hatred was in her heart. Confronting that nurse is something that I am not

proud of but I really have to stand up for myself. I may be tagged that I have

temper but if I did nothing it will haunt me. I should have done that in a

professional manner.

ANALYSIS:

Medical errors are something all of the nurses have to be concerned with

and this is why it's a required for the professional nurses to abide and be guided

with the Ethico-Legal Standards of Nursing. This person that calls herself a nurse is

lacking in many respects.

Nursing does not have room for egos like this. We are there to serve the

public who need us to do our jobs and not behave like fifth grade girls who are

trying to find a place among their peers, when we are adults who have worked

hard to get through nursing school. We have learned compassion and empathy

for others before getting down to the business of studying and taking

responsibility once we become a nurse. I have discovered that many adults


6/8

Page 41

have never grown up past that elementary level and with that being said....this

nurse has no business being a nurse with her attitude and childish behavior.

If I were the nurse, I would give the supervisor or director of nursing a

heads up to be ready for anything this poor excuse for a nurse has up her sleeve

in the future. That way, she will be ready for her and hopefully she is aprofessional who will let her know that this nonsense is grounds for firing her.

Lesson learned: If someone committed an error, it does not mean that for

the rest of her life she will make mistake. It's the way of learning. Do not judge

the person based on first impression. You don't have to like the person personally

for you to be able to get along with at work. There is an overwhelming evidence

that the higher the level of self-esteem, the more likely one will be to treat others

with respect, kindness, and generosity.


7/8

Page 42

C. INVOLVEMENT OF MANAGEMENTTHE SITUATION:

NURSE:I work in a large unionized hospital in the OR dept. in the evening shift.

We have a coworker who we (nurses, scrub techs, surgeons) believe to be a

dangerous nurse. He is unable to provide safe patient care without constant

intervention.

no one feels safe working with him in the OR setting because he is: paranoid,has tunnel vision, unable to multitask, freezes- literally freezes, lies- incapable of

admitting any mistakes, cannot prioritize, unable to function at a basic novicescrub/circulator nurse level in the OR without calling the charge nurse for helprepeatedly during a single case, fails to anticipate and act quickly when

circumstances change- i.e. laparoscopic to open...

He has been in the OR for over 10 years, this is his second career- sued his firstcareer employer for $$$ and was paid to be trained in this career. He has beenon/off of workers comp multiple times for extended periods of time for

questionable injuries (he has his own doctor), accused coworkers of threateninghim, for discrimination....

We (even surgeons) have individually written him up multiple times, we have

spoken with our DA's multiple times (they are scared of him and/or don't care),nothing is done and we suffer- emotionally and physically. Morale is extremely

low; we fight each other about our "rotation" with him.

its so difficult to describe what environment is like- you are forced to do his jobas well as your own for the patient's safety all the while feeling paranoid that heis setting you up for another workman's comp claim or lawsuit- said he was

choked when getting gowned up, ran and stuck his foot under an emptygurney and claimed injured toe, brushed against a coworker holding surgical

equipment and claimed that person hit him with said surgical equipment ( didn'tnotice there was a witness)....

Weve even discussed getting a petition refusing to work with him for our

patient's safety and our personal safety/license. Weve discussed obtaining a

lawyer because our supervisors are aware of the situation but unwilling to do

anything.


8/8

Page 43

ANALYSIS:

The nurse should get risk management involved and document with incident

reports. Just because the nursing and medical administration is aware of thesituation, the nurse can't assume that risk management has been informed.

They're an entirely separate group, an entity which administration of different

area sometimes doesnt want to involve because they want to do things their

way.

As for the incident reports, the nurse should make absolutely sure that the

accounts are factual, non-emotional and objective in nature. Incident reports

are not the place to vent. The nurse should make a lengthy and detailed paper

trail of what occurs and what detrimental effects it has on patient care. Ifanother nurse has to be called in, that results in a longer time under anesthesia.

If the Chief Nurse receives a complaint directly, it is supposed to be logged and

followed to a conclusion. It is supposed to occur in conjunction with advice from

the Ethico-Standards of nursing, so that the facility is in compliance with the

Philippine Nurses Association (PNA).

case analysis on clinical incident

Documents