Reference no: EM133855131
To Tell or Not to Tell (Marquis & Huston, 2012)
You are a new graduate nurse working in an acute care hospital. You are very conscientious about your care but have just discovered you made a mistake today. About 30 minutes ago, you went into Room 1308 to give Lasix to Ms. Sanderson in bed A and Coumadin to Ms. Jarvik in bed B. Just as you handed the Lasix to Ms. Sanderson, the code alarm sounded for one of your patients down the hall. You set down the med pass tray on her overbed table and told her you would be back just as soon as possible. You then responded to the code, which ended successfully several minutes ago. When you return to the room to finish passing your medications, you find Ms. Jarvik's pill cup empty. Ms. Sanderson is confused and does not remember if she took the pill or what she did with it. Ms. Jarvik is also confused and is unaware that she did not receive her intended medication.
When you report to the charge nurse what occurred, she lowers her voice and tells you to "just forget about it. It was one low-dose Coumadin pill and likely wouldn't have any impact on Ms. Sanderson anyway." She goes on to say that if you fill out an Adverse Incident form, that she will have to notify Ms. Sanderson's short-tempered physician as well as the nursing office. The hospital was recently cited for several small infractions by The Joint Commission (JC) and tensions are running high about all types of medical errors. In addition, she says that a copy of the Adverse Incident form will be placed in your personnel file, which could have ramifications for you in terms of your 3-month performance appraisal as a new nurse. She also says that neither of the patients would ever know that an error occurred.
Finally, she shares that the culture at the hospital around medical errors is "blame and shame," not "report and learn," and asks you to think twice before pursuing the matter. She says that because of the recent JC sanctions, the hospital is adopting a zero-tolerance approach to preventable errors and your job might even be at stake.
Questions:
- What will you do?
- What alternatives could you consider and what are the driving and restraining forces for each possible choice?
- What are the relative risks to both patients and the possible costs to you?
- What is your professional obligation in terms of reporting?