Assignment task: Can you please provide some help?
You are the nurse manager for a 22-bed intensive care unit. JB is a client in that unit following a six (6) vessel aortocoronary bypass this evening. He returned directly from surgery approximately 30 minutes ago. Jasmine is the receiving nurse. She works with the OR team and two (2) other ICU nurses to admit and stabilize JB. Once she has completed stabilizing him, she looks at the printouts of orders that the Unit Coordinator placed on her charting table. Although the facility uses electronic physician order entry, it currently does not have a full electronic health record. All orders print at the nurses' station and are regularly distributed (paper printouts) by the Unit Coordinator. One of the orders on her charting table reads to transfuse two (2) units of packed RBC's over 1 hour each. Jasmine sends the patient care assistant (PCA) to the blood bank to pick up the first unit (acceptable by hospital policy). She then checks the unit against the client's arm band with a second registered nurse and hangs the first unit. After Jasmine sends the PCA to obtain the second unit, the blood bank technician tells the PCA that there are no orders for JB to receive blood. When Jasmine looks at the printout of the order, she notes that the Unit Coordinator left another client's order on her charting table. She immediately realizes that she and the other RN never checked the first unit of blood against the order itself. Jasmine notifies the healthcare provider, obtains orders, and completes the incident report. When you come to work the next morning, you find Jasmine sitting outside your office, visibly upset, and telling you that she made a terrible mistake and wants to resign. You immediately recognize that Jasmine is a secondary victim of medical error.
Prior to answering the following questions, you should read these two articles:
- Secondary Victims of Medical Error (AHRQ):
- Second Victims (TJC):
1. Define Secondary Victim.
2. What are your immediate steps?
3. How do you assess the other nurses involved in JB's care last night to determine if any are also secondary victims of medical error?
4. You review the incident report, and your director recommends that the unit complete a root cause analysis (RCA) to minimize the risk of this ever happening again. Jasmine and the other nurses involved in the care of JB that night are a part of the RCA team. Why did the director recommend a root cause analysis when JB experienced no harm?
5. You are chairing the RCA team. How do you facilitate obtaining the required information for a successful root cause analysis while supporting Jasmine (and possibly the other nurses) as they go through the stages of being a secondary victim of medical error without making them feel victimized?
6. As part of the root cause analysis, you determine the following facts: 1. The operating room failed to transfer JB to the ICU in the computer system until he had been in the ICU for well over an hour. The PCA was able to obtain the first unit of blood because the blood bank saw the client in the OR when checking the computer and the policy of the blood bank is to release blood to the OR upon request as anesthesia orders and administers the blood. 2. JB did receive blood that was typed and cross-matched for him. There was no blood incompatibility. JB suffered no adverse effects. 3. The CV surgeon stated that he would have ordered two (2) units of blood when he rounded later that evening based on JB's immediate post-op labs. As it was, he did order one (1) additional unit. How do you use this information in your support of the nurses who are secondary victims of medical error?
7. A few days later, you enter the breakroom and hear a few of the day shift nurses discussing the error. The consensus of what you overhear is that they felt the nurses were dangerous and should be fired and that a number of other nurses in the unit agree. The talk stops as soon as one of the nurses sees you in the doorway. You know that none of the nurses who cared for JB that night had any significant errors previously and all had worked in the ICU for at least five (5) years. How do you address the lack of peer support of secondary victims of medical error being evidenced? Can hearing about these conversations affect Jasmine's or any of the nurse's recovery from being a secondary victim of medical error?
8. Using the principles of Fair & Just Culture, did these nurses make a human error, engage in at-risk behavior, or engage in reckless behavior? Should the type of behavior determine whether the organization will support a care provider who is the secondary victim of medical error?