A patient was admitted to the medical surgical unit for the emergency room. New admissions require labels and a demographic printout be printed and accompany the patient to the unit. This unit uses electronic charting as well as paper charting for the physicians. The paper chart contains; blank medical orders sheets for the physician, printouts of lab, and X ray results, discharge orders, medication orders, history and physical, and do not resuscitate orders. The charts have dividers for each section and the sheets are labeled with the patient’s identification labels. The patient was admitted to the unit as per policy. A copy of the admitting orders and medication orders were distributed to the admitting nurse on the unit. A medication was to be administered to the patient after admit to the unit was complete. The nurse looked at the order for verification and the patient identification to double check before administering the medication. When checking the physician order, against the patient identification the nurse identified an incorrect patient label had been placed on the physician order sheet for the medication.
The order sheet had already been faxed to the pharmacy and placed in the patient’s chart. The mistake was brought to the attention of the unit manager immediately, leading the way for a new policy and procedure for labeling patient documents, storing labels, and stuffing charts. The event that occurred could have led to a sentinel event by administering the wrong medication and causing harm or death to the patient. The incident could have had an effect on all the areas that care for the patient. The manager of the unit quickly notified the pharmacy, the nurses on the unit, the patient’s physician, and the unit coordinator. The chart was quickly reviewed for any other mislabeled information as well as the other charts on the unit at that time. The manager formed a team from the staff on the unit to conduct a root cause analysis using the Ishikawa or fishbone diagram. Describe and Analyze Theory/Style
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The management style used on this unit was transformational leadership. This leadership style used by the manager empowered the employees to participate in the unit by open communication, promoting new or better ideas and feeling part of a team. The five principles of this style of leadership were used as the team was formed and the process of change was recommended, the five principles of transformational leadership: Yoder and Wise (2011, p. 40)
1. Challenging the process
2. Inspiring a shared vision
3. Enabling others to act
4. Modeling the way
5. Encouraging the heart
The use of these principles helped the manager to include all the members allowing them to see they were part of the solution and not part of the problem. The unit already had a policy in place for labeling, storing and stuffing charts. The manager and the teamed challenged the process already in place to prove a better way to provide this service reducing the risk of this event reoccurring. Inspiring a shared vision from the team formation, allowed them to act on the situation, model a new and improved way of performing these tasks and encouraging others to have the confidence to speak up and participate in events allowing them to build confidence as professionals.
The occurrence of mislabeling orders or patient information has been an issue in all facets of the hospital environment, a study from the Dunn, Edward, Moga, and Paul (2010) showed this affected lab specimens as ours affected the patent physician orders. This showed this event was not limited to just one area of patient care but all areas could be affected. The study reviewed 227 root-cause analyses by the team involved. They all shared the vision of making recommendations for improvement to the system, improving the communication through informatics, evidence-based practice, teamwork and collaboration providing an environment that is patient centered and the best opportunity for safe practice. Another case study reviewed by, Courtney, James, Boyer, and Edward (2008).
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This identified same problem; the wrong label was applied to the wrong patient information. This patient was given a dose of the wrong medication and was hospitalized for the incident receiving a dose of opioids instead of the ordered medication vancomycin. According to the FDA Medwatch Safety page in the above article the 273 reports made 68 or 20% of the 273 reports were labeled as a labeling error. Critique Handling of Situation/Resolution with QSEN
The situation was resolved prior to the patient receiving the medication. This event constituted a review and change to the current policy for the medical surgical unit. The labeling of patient information storing labels and stuffing charts was the issue reviewed. The transformational leadership style used by the unit manager initiated the solution to the problem. A root-cause analysis and action plan addressed the cause and effect of the incident. The team formation addressed the questions from the root cause analysis: What were the details of the event?
A, The incorrect patient label discovered on the physician order sheet with medications. What areas were impacted?
A, The medical surgical unit, ancillary departments were impacted. The process of activity in which the event occurred, what are the steps in the process? See attached chart diagram, pg,7.
What steps were involved or contributed to the event?
A, Pulled wrong label from folder
B, Chart not previously stuffed with order sheet, unlabeled placed in chart.
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C, Labels placed in wrong folder
D, No double checking of charts
E, Labeled more than one patient’s chart at a time
F, Charts were not stuffed and prepared
What potential human factors were relevant to the outcome?
A, Lack of orientation/training
B, Staff variable, RN, LPN, UC, CNA
C, Lack of communication
D, Staff not held accountable
E, Policy outdated
F, Lack of staff
What controllable environmental factors affected the outcome?
A, Position/storage of labels
Were there external factors beyond organizations’ control?
A, Peak activity
B, Distractions
C, Multiple admits to the unit in short time.
An action plan was made from the above questions after review of the situation. This would have been an action that I tried to achieve in this situation. The elimination of the folders that stored the labels at this time, and the labels would be place in the front of the charts. The creation of a procedure to stuff charts and inform all staff on the unit with training. It would be part of the new employee training to the unit. Encourage the use of computerized physician order entry, and implement computerized verbal order entry for the nursing staff. Reduce the noise on the unit by education to the staff and implementing a noise meter to remind the staff to be quiet. The recommendation of the team was to monitor the medication safety reporting to make sure of the reduction or reoccurrence of this type of incident.
The resolution of the incident incorporated all of the QSEN competences. The unit acted on the situation quickly providing patient safety, by identifying a problem and notifying the manager. The manager notified the pharmacy and took action to have the chart and the rest of the chart reviewed providing safety and patient centered care. A team was formed to analyze the problem and make recommendations for improvements, empowering the staff to share with decision making and promoting communication and provide quality care. The team reviewed the old policy, cause and effect of the problem, previous case studies of issues similar to this one providing evidence for the recommendations made in the action plan. The recommendations included electronic order entry, reviewing the medication safety reports to provide quality improvement of the situation making sure this does not reoccur.
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The whole process provided a plan, action and evaluation to promote the best patient care by recognizing the potential; for failure and addressing it before it happens. I do not think I would have changed any of the actions taken by this manager if I was in her place. The chart review during the shift was something I might have added for reinforcement of safe practice. I have attached a diagram of the process in question 3 was part of the process of change and a fishbone diagram used for the root cause analysis.
References
Courtney James Boyer Edward 2008 Case Files of the Universtiy of Massachusetts Fellowship in Medical Toxicology: Lethsl Dose of Opioids Contained in a Elastomeric Capsule Labeled as Vancomycin.Courtney, James, Boyer, & Edward (2008).
Case Files of the University of Massachusetts Fellowship in Medical Toxicology: Lethal Dose of Opioids Contained in a Elastomeric Capsule Labeled as Vancomycin. Journal of Medical Toxicology, 4(3), 192-196. Retrieved November 4, 2011, from http://login.lib-proxy.uis.edu/login?url=http://search.proquest.com.lob-proxy.usi.edu/docview/196342901/ Dunn Edward Moga Paul 2010 Patient Misidentifcation in LAboratory Medicine: A Qualitative Analysis of 227 Root Cause Analysis Reports in the Veterans Health Administration.Dunn, Edward, Moga, & Paul (2010).
Patient Misidentification in Laboratory Medicine: A Qualitative Analysis of 227 Root Cause Analysis Reports in the Veterans Health Administration. Archives of Pathology & Laboratory Medicine, 134(2), 244-255. Retrieved November 6, 2011, from http://login.lib-proxy.usi.edu/login?urt=http://serach.proquest.com.lib-proxy.usi.edu/docview/211049761 Dunn Edward Moga Paul 2010 Patient misindnetifcation in laboratory meidicne: A qualitative analysis of 227 root cuse analysis roeports in the veterans health administration.Dunn, Edward, Moga, and Paul (2010) Yoder Wise 2011 Leading & Managing in NursingYoder, & Wise (2011).
Leading & Managing in Nursing (5th ed.).
