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CASE ANALYSIS: CLINICAL INCIDENT A. PATIENTS SAFETY THE SITUATION: NURSE: I received an order from doctor to run a potassium bolus over 1 hour. When the potassium came down from pharmacy they had typed on the label to run it over 1 1/2 hrs. I had read somewhere that potassium should not run faster than 10meq/hr peripherally which at the concentration supplied would have been over 1 1/2 hrs. So I asked my preceptor which one I should go with. She said that I should always follow the MD's order, but that if I was worried about it then SHE would hang it. (I think she was tired of me asking questions.) So she goes into the room, hangs the potassium (which I had already primed), sets the pump to run it in over 1 hr, hooks it up to the patient, and she leaves the room. Well a few minutes later I heard the pump beeping so I went in to check it. In her rush, the preceptor had not hooked the tubing up to the pump (even though she had set the pump) and the potassium would have been running in at a wide open rate. Fortunately, for some reason, when I primed the tubing I had clamped it off and when the preceptor hung it she did not unclamp it which caused the pump to beep. So the K+ did not run in at the wide open rate that it would have. I told the preceptor about this and she said that I needed to stop worrying and that it is okay for potassium to run without a pump. (She did not mention anything about it running wide open). She said that there will be times when I dont have a pump and I will have to run it without one. ANALYSIS: A potassium bolus run too fast can cause an MI that would kill the patient. Potassium can also extravasate and cause necrosis to the surrounding tissue. Even giving potassium at the prescribed rate, via a pump, causes a lot of irritation to the vein and patients c/o pain at the site. The hospital should have a policy on running IV Potassium. The nurse should call the Pharmacy and have them print a copy so that the nurse can show it to her preceptor.

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No matter what the doctor prescribed, the nurse will be held to the nursing standard of care. It is a prerequisite to follow hospital policy. If the MD prescribes something that hospital policy does not allow, it's the job of the nurse to call him and inform him and get the order changed. If he won't change it, the nurse should go up of command and get your supervisor to talk to him. Either the charge nurse or supervisor should always be prepared with the situation when there is a need arise to talk to the MD themselves.

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B. INVOLVEMENT OF COLLEAGUE THE 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 the medication. 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 and was 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, she just said gives it to the patient. I was looking for the medication card and she said 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 my head nurse, "The patient got hurt a little when I gave the meds" so she asked why. 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 so nervous 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 sure nothing 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 worried during 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 that mistake 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 were irritated 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 was thinking, 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 not know 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 in the 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.

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Just a few weeks ago (I've been working in the hospital for almost a year now) I heard 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 for months and this time she went overboard. I went to their nurse station and confronted 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

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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 a professional 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.

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C. INVOLVEMENT OF MANAGEMENT THE 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 novice scrub/circulator nurse level in the OR without calling the charge nurse for help repeatedly 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 first career employer for $$$ and was paid to be trained in this career. He has been on/off of workers comp multiple times for extended periods of time for questionable injuries (he has his own doctor), accused coworkers of threatening him, 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 job as well as your own for the patient's safety all the while feeling paranoid that he is 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 empty gurney and claimed injured toe, brushed against a coworker holding surgical equipment and claimed that person hit him with said surgical equipment ( didn't notice 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.

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ANALYSIS: The nurse should get risk management involved and document with incident reports. Just because the nursing and medical administration is aware of the situation, 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. If another 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).

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