Description of a critical Incident
Philipp and Collins were both admitted to the hospital at the same time. Phillip suffered an embolic cerebrovascular accident while Collins had rectal bleeding. The two were carefully attended to and left to wait for further diagnosis from the head physician who was still attending to other patients. A new nurse entered where Collins and Philipp were waiting for further diagnosis. Both patients had their medical records with them at the time of admission, but the nurse did not check on the medical records. She administered medication to both patients. Although the patients were perplexed why they were given the drug, they trusted the nurse understood their unique ailment and condition. Philipp and Collins were later shown to their wards after completing their diagnosis. After a couple of hours, Collins started showing reactive signs. He grew pale, his eyes turned red, and he had difficulty in breathing. A nurse came to attend to him and realized that Collins needed urgent attention. It was by luck that he received immediate attention and was rushed to the ICU where his condition stabilized after a series of injections. A close examination revealed that he was given the wrong medication. The nurse involved owned up and was reprimanded by the management.
What worked well and what did not
Quick response from the nurse on duty saved Collins life. By quickly transferring the affected patient, the ICU, the nurse raised the stakes, and prompt action from the physicians helped the situation. The physician’s diagnosed the wrong dosage on the patient’s blood and took the necessary measures to neutralize the effect and the resulting changes in the patient’s body. The patient responded well to the quick actions and was able to regain his status after four days. During the four days, he was kept under strict monitoring by the doctors, and his state restored pretty well. He was later referred back to the wards to continue with his treatment and medication.
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Reflection of the incident, what the breakdowns were and why they occurred
The incident was rather unfortunate, and it can best be termed as “accidental.” Taking a look at the patient’s records could not have taken the nurse much time. In her hurry to attend to other patient’s, she administered the drugs to the wrong patients.’ I believe that it was not her wish, and the incident was an unfortunate accident. The nurse has a reputable historical background. Over the years, she earned the commendation of the administration in upholding patient safety standards and policies in the health facility. Thus, the day’s unfortunate incident was never intentional.
Steps a leader/manager can take to prevent future incidents /creating an environment where these incidences are less likely to happen
The above incident is an example of a lack of effective communication between health care providers. At the same time, it is a clear indication of a lack of collaboration and teamwork within the medical facility. Okuyama, Wagner and Bijnen (2014) argue that e verybody tasked with patient safety has an overall responsibility to ensure that patients are safe during their medication and diagnosis within the healthcare facility. However, nurses bear the most significant responsibility for patient safety. However, Ulrich and Kear (2014) argue that medical errors, due to human mistakes, may often lead to adverse effects during patient treatment. All healthcare practitioners undergo intensive training inpatient care. However, to improve patient safety and avoid adverse effects and unintended results, it is critical to observe safety measures. Ulrich and Kear (2014) maintain that c reating a safe working environment and adhering to tips that promote patient safety is mandatory for any healthcare facility.
In the above incident, the nurses lacked coordination on the patient’s diagnosis and treatment plan. Good hospital design has in place evidence-based standards that all physicians and nurses follow to ensure that they understand the condition and status of each patient ( Okuyama et al., 2014) . For example, a well-defined principle helps in reducing medication errors in which the nurses have to read through each patient’s medication or prescription to understand their needs and treatment plan ( Ulrich & Kear, 2014) . The nurse who administered the drugs to Philipp and Collins failed to check their medical report, an incident that led to wrong drug admission.
Although the patient was attended to on time, it recommended that a healthcare facility build a robust and capable team able to respond to an emergency in time to minimize further harm to a patient. A healthcare facility should have in place a Team Strategies and Tools to Enhance Performance and Patient Safety. TeamSTEPPS offers evidenced-based strategies that promote effective communication in addition to teamwork abilities to healthcare practitioners ( Okuyama et al., 2014) . The approach is part of a rapid response system that helps attend to patient accidents, adverse effects, and unintended outcomes.
Unintended outcomes can significantly be minimized if durations of shifts by nurse’s and hospital staff are limited. Ulrich and Kear (2014) further maintain that exhaustion is the number one factor leading to mistakes and human errors. According to an investigation into the above incident, the affected nurse had been on duty for the past 36 hours. The affected nurse was scheduled to hand over her responsibilities to a different nurse, but she was requested to stay longer due to the high number of patient admission. It is critical for nurses and healthcare practitioners to get ample sleep and stick to the 80-hour work-week parameters. Okuyama et al., (2014) maintain that anything beyond this is bound to lead to extreme exhaustion that may trigger to human errors, careless mistakes, and poor attention. At the same time, nurses treating and attending to patients require up to five-hour mandatory uninterrupted sleep.
Hospitals and healthcare facilities are often urged to work hand in hand with the Patient Safety Organization. According to Okuyama et al., (2014) the primary purpose is to share and report on patient safety issues. Patient Safety Organizations work towards helping avoid preventable mistakes such as the admission of wrong medication and wrong diagnosis. According to Ulrich and Kear (2014) PSO’s also help in creating a secure patient environment in which healthcare providers can use to analyze, aggregate, and collect data towards improving patient safety. PSO’s helps reduce such by minimizing hazards and risks related to patient safety and care.
Breakdowns, unintended outcomes, human errors, and accidents are often bound to lead to grave adverse effects. The above incident could easily have been avoided by close collaboration between the medical team, effective communication, and attention to details. However, due to human error once in a while, accidents occur. However, by adhering to patient safety and observing healthcare guidelines on medical practice, it is possible to minimize such adverse effects and unintended outcomes. Patient safety remains one of the essential concepts of health practice.
References
Okuyama, A., Wagner, C., & Bijnen, B. (2014). Speaking up for patient safety by hospital-based health care professionals: a literature review. BMC health services research , 14 (1), 61. https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-14-61
Ulrich, B., & Kear, T. (2014). Patient Safety and Patient Safety Culture: Foundations of Excellent Health Care Delivery. Nephrology Nursing Journal , 41 (5). https://www.semanticscholar.org/paper/Patient-Safety-and-Patient-Safety-Culture%3A-of-Care-Ulrich-Kear/205ef39c7e157fbda457434fe56768937d1d2674
