Patient Safety Case Study

There was a Patient/staff safety issue. The nurse failed to follow a policy of administering an elliptic medication. She left the radioactive medication unattended in a patient room and left the room to bring something. While the nurse was out of the patient room, the mother of that patient was yelling for help because the patient has had an epileptic episode. This issue has happened two weeks ago when the manager was on vacation. So that, the manager went through an investigation process and used human resources. She involved all the individuals who witnessed this event like the patient and his mother, nurse, and someone else (I don’t remember what his position is), but at the same time she tried to make private as much as possible. The …show more content…
There was a miscommunication between two staff during the shift report in the morning. A patient asked for pain medication at the end of night shift, so that the night shift nurse brought the medication from the inpatient pharmacy and asked the morning shift nurse to come with him to the patient room to give that patient the medication and do the report at the bedside. The morning nurse was not willing to have the report at the bedside, so that she asked the night shift nurse to go and give the patient the medication and then return back to the station for shift report without even saying please do this for me. The night nurse then gave the morning nurse the medication and stated that my shift has already ended and you should thank me that I brought the pain medication. Actually, I didn’t attend this issue because it has happened before I came, but the manager told me that the two nurses should solve this issue between themselves because their are adults and she told them that she didn’t witness what has happened. She also emphasized for them that what is important for her is the fact that the patient is needing the pain medication. The manger assumed that the morning shift behaved in this way because she will leave the unit …show more content…
I also met two of my goals regarding learning the resources that manager use to make good decisions and solve problem, and the different ways of effective communication are used. Again, I felt from the two staff issues that the relationship between staff is not strong. I know that everyone has a unique personality, so that a leader needs to understand the individual who is in-front of her and know the effective ways to approach this person. I has assumed that adults in their work places when they make mistakes, they take the ownership of their mistakes and learn form these mistakes. However, if it is the first time for that individual, it is usually difficult to admit mistakes. I felt that this moment of discussing the incident issue is always difficult for both the manager and the staff. Interestingly, the manager didn’t lost control during the meeting with that nurse when they discussed the sensitive issue. I appreciated her behavior to remaining calm even when that nurse started to reflect negatively about the manager and other nurses. For me, it was frustration to hear that she didn’t take the ownership of her mistake and not being professional during that conversation. At that moment, I realized that dealing with staff in a such of sensitive issue