Undocumented nurse medical errors - Essay Example

? Undocumented nurse medical errors Submitted to Dr. Deb Bennett-Woods in partial fulfillment of HCE 430 – Health Care Ethics Regis University February 4, 2012 Case Presentation It was my first day at my first job. My nurse trainer was evidently flustered with her numerous tasks in the hospital. I followed her to a patient’s room, where she administered medication. The patient was recovering from a car accident, where he suffered from some chest and abdominal trauma, as well as a badly-broken leg. I was confused, because the name on the door was not the same in the med chart. I returned to the nursing station, where she documented the medication. After opening the patient’s chart, she was distressed to find out that she gave the wrong medicine. She checked the patient’s chart for allergies and was comforted that the latter had no allergies with the incorrect medication. However, the patient complained of dizziness and nausea later on, and the nurse did not provide the pain meds as scheduled. The patient also showed signs of discomfort for several hours. The nurse closely watched the patient all evening and up to the next shift, since she volunteered to cover it because a nurse called in sick. The next evening, this same patient was assigned to me. I checked his chart and was surprised that the medication error was not documented, and that the normal dose of pain medication was documented. During my dinner break, the patient had difficulty in breathing and went into arrest. The patient died and autopsy showed that he died from an embolus to the lung. This was a probable unavoidable complication of the injuries. But since the patient experienced pain the evening before, his family members believed that the nursing staff neglected to observe him for complications. They said that they consider suing the facility and I know that I will be named in the suit. Case Study Analysis: 8-Step Model for Ethical Decision Making The case with this patient involves an ethical dilemma of reporting the medication error of my colleague. I will examine this case using the 8-Step Model of Ethical Decision Making (Bennett-Woods, 2001). I will determine the facts of the case and all information needed to properly analyze and resolve this issue. I will state the practical problem, identify the most important ethical questions and the theoretical bases for my analysis, discuss arguments and counterarguments, including their specific ethical concepts and supporting facts, name options, and choose and explain my final decisions. Step One: Gather Relevant Information Clinical indications. Patient was recovering from a car accident, where he suffered from chest and abdominal trauma and a badly-broken leg. The most common effects of car accidents are head, chest, pelvis, and abdominal trauma (Schmucker et al., 2010). The patient complained of dizziness and nausea, which can be the result of his injuries or the incorrectly given medicine. One of the primary tasks of nurses is drug administration and it occupies around 40% of their work time (Armitage & Knapman, 2003, cited in Tang et al., 2007, p.448). Administering drugs have become more complex, especially when there were only 656 medications in 1961, but now there are more than 8000 medicine being prescribed, with more than 17000 trade and generic names in North America (Tang et al., 2007, p.448). Giving medication is “one of the most error-prone steps of the medication-use process, with 34% of all errors originating in this phase” (Bates et al. 1995, cited in Helmons, Wargel, & Daniels, 2009, p.1202). Some studies discovered that medication errors normally take place during the prescription and administration stages and can compose 65% to 87% of the total number of medication errors (Bates et al. 1993, 1995; Benjamin 2003, cited in Tang et al., 2007, p.448). Less than 2% of incorrect medication actions are not intercepted by the patients’ bedside (Helmons, Wargel, & Daniels, 2009, p.1202). The patient also showed signs of discomfort for several hours. No pain medication is given. Pain management is one of the most challenging responsibilities of critical care nurses (Helms & Barone, 2008). Pain assessment is an important role of nurses, and it is critical that nurses know the signs and symptoms of different kinds of pain that can lead to its recognition (Fear, 2010, p.39). The next evening, the patient had difficulty in breathing and went into arrest. Cardiac injury is a considerable cause of death in trauma patients and can be derived from either blunt or penetrating means (Berg, Talving, & Inaba, 2011, p.35). Motor vehicle collisions (MVCs) can result to cardiac injury (Maron & Mark Estes, 2010, cited in Berg, Talving, & Inaba, 2011, p.35). The patient died and autopsy showed that he died from an embolus to the lung. This was a probable unavoidable complication of the injuries. Chest trauma can result to embolus to the lung. Medical errors are attributed to be the cause of 44,000 to 98,000 deaths, which is more than the deaths caused by vehicle accidents, breast cancer and AIDS (Kohn et al. 1999 cited in Sheu et al., 2009, p.560). Medication error deaths have increased by 2.6 times since 1983 (Sheu et al., 2009, p.560). Patient preferences. The patient did not directly ask for pain medication, but it is possible that he wanted it after experiencing dizziness and nausea. The patient was not verbally expressive of his conditions, such as his pain and discomfort. The nurse trainer observed discomfort and watched him closely. Quality of life. Indications showed that the quality of patient’s life dropped either as a result of his chest and abdominal trauma or the incorrectly administered drug. It is possible that he experienced extensive chest trauma and injuries, from which he could not recover. External factors. Organizational factors. Nurses are expected to report medication errors in patient’s charts. The organization requires reporting of medication errors. Many nurses do not report their own medication errors, primarily because of fear of punishment, such as corrective action, termination from the job, and getting disciplinary action from the State Board of Nursing (Schelbred & Nord, 2007, p.318). Some of the organizational causes of nurse medication errors are work overload (Schelbred & Nord, 2007), work duration, and work-related stress (Hewitt, 2010). An article reported that: “In a survey of 2121 medication errors, 67% of actual errors and 60% of near misses had not been reported” (Huber, 2002, cited in Sheu et al., 2009, p.561). Poor policies and system in reporting nursing error can lead to lower reporting and documentation in charts. Professional factors. Poor training and education can lead to nurse medication errors (Hewitt, 2010). Provision 2 of the ANA Code of Ethics states: “The nurse's primary commitment is to the patient, whether an individual, family, group, or community.” Provision 3 of the ANA Code of Ethics states: “The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.” Provision 4 of the ANA Code of Ethics states: “The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse's obligation to provide optimum patient care.” Provision 5 of the ANA Code of Ethics states: “The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.” Legal factors and precedents. Legal precedents on reporting medication error vary from state to state. Medication errors due to negligence can result to nursing malpractice allegations. Torts are applicable for medical negligence. Torts on not reporting colleagues’ medication errors are not familiar to me. Social factors. Family members asserted the importance of observing possible complications, including their member’s pain. Family members placed the main responsibility of caring to the nurses. Step Two: Identify the Practical Problem The practical problem is whether I should report my colleague’s former actions and to whom, especially when I am at risk of “paying” for someone else’s mistakes, if the medication error actually resulted to the patient’s death. Step Three: Identify the Ethical Issues and Questions This case raises several ethical issues, as well as a legal concern, and they are the following: Did the nurse do the right thing of not accurately reporting her pain medication actions in the chart and not informing anyone else about her mistakes? Was it my personal and professional duty to ensure that she wrote her medication error and withdrawal of pain medication in the patient’s chart? Am I liable to the court for not reporting my colleague’s medication error? I have determined the following primary and secondary ethical questions that I will based my analysis on: Primary Question: Should I report a colleague’s medication error? Secondary Question: To whom should I report my colleague’s medication error? Step Four: Select the Ethical Principles and/or Theories to be Considered I will consider the following ethical concepts and theories in answering the ethical issues and questions above: Utilitarianism- An act is good depending on the level of goodness that it produces. Actions are considered right if they can result to the greatest amount of happiness to the greatest number of people. Kantianism- Kantianism is considered a form of deontological ethics, because an action is deemed as right or wrong, depending on the action itself. Kant argues that actions are right if they can be universalized, and when people are not treated as means to ends alone. Duties are also important to Kant. An act is good if it is done out of one’s duties. Acts that come from self-interests and convenience are not considered as good. Respect for patient autonomy- Patients should be allowed to make decisions regarding their health care. Fidelity- This can mean loyalty to colleagues or the organization or the patients. Beneficence- It is the principle that aims to promote the welfare of patients by preventing or eliminating harms. Nonmaleficence- It is the principle, which stresses that health care professionals should not harm their patients. Justice- It is the principle of fairness, where the individual is given what is owed to them or what they deserve. Accuracy- Nurses have duties to accurately report activities, including drug administration. Relativism ethics- Everyone has their own ethical beliefs and practices. One culture’s ethics should not be imposed on others. Step Five: Conduct an Analysis and Prepare a Justification The patient is undergoing pain and discomfort because of his chest and abdominal trauma, including his fractured leg. Beneficence says that nurses should promote the welfare of patients by preventing or eliminating harms. It means that I should ensure that I can do everything possible to help him recover from his injuries, and this includes administering the right drugs. Provision 3 of the ANA Code of Ethics supports beneficence and states: “The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.” The problem is that the nurse made a mistake in giving the wrong medicine. It is wrong to give the wrong medicine, because it might harm the patient. In addition, she did not inform anyone of her mistakes. This is also against the welfare of the patient, since the possible effects of the medicine cannot be properly examined and observed. Furthermore, nonmaleficence is the principle, which stresses that health care professionals should not harm their patients. By not reporting what she had done, the nurse might be harming the patient. Although not all medication errors lead to worsened conditions or death, it is her obligation to not harm the client, indirectly or directly. I might have also harmed the patient by not intercepting when I believed that the name on the door is not the name I recall from the med chart. I also did not intercept when I realized that my peer did not document her medication error, while she documented pain medication that she did not give. Nurses should also respect patient autonomy. Patients should be allowed to make decisions regarding their health care. Since the nurse trainer did not inform the patient of her mistake, she reduced his autonomy to make succeeding decisions for his health care condition. Furthermore, it is his right to have pain medication, unless he expressly denies their administration. The nurse trainer took it upon herself to not administer pain drugs without asking the patient. Justice is the principle of fairness, where the individual is given what is owed to them or what they deserve. The patient deserved to know that something incorrect happened. He was supposed to receive the right drug at the right dosage and at the right time, but he did not. It was not fair for him to not know what was happening to his own drug administration. In addition, he did not receive timely pain medications. He deserved to have his pain eased because of the extent of his injuries. Nurses also have duties to accurately report activities, including drug administration. They have the responsibility to maintain accurate and factual medical charts. The nurse did not report her medication error, and she documented a normal dose of pain medication, though she did not administer it. Based on these ethical concepts and principles, the nurse did not do the right thing of not accurately reporting her pain medication actions in the chart and not informing anyone else about her mistakes. Moreover, it was my personal and professional duty to ensure that she wrote what she actually did in the patient’s chart. I should have communicated with her regarding the need to report her errors on her own, or I would be forced to report her instead. Without these actions, my intentions to protect her might be construed as negligence of my duties and I might be partially held legally liable for what happened to the patient, if it can be proven that he died because of the wrong medication. The main ethical question is: Should I report a colleague’s medication error? Kantianism will stress the importance of duty. The main duties of nurses are to promote the interests and welfare of the patient. My loyalty should not be to my colleague or hospital but to the patient first and foremost. In addition, it will also not be good to not report medication errors. If this act is universalized, it will erode public trust on nurses and the health care sector, in general. Finally, not reporting this medication error will deem that I am using the patient as the means to my end, where my end is to protect myself from professional, legal, financial, and social repercussions of my inability to act as a nurse. Kantianism indicates that it is wrong to not report medical errors and to not accurately document it. The secondary ethical question is: To whom should I report my colleague’s medication error? First, I should inform my colleague to report what she has done. This will ensure a more accurate investigation on the death of the patient. It might even prove that her mistake did not lead to the patient’s death. Second, I, or the nurse trainer, should inform the hospital administration about the medication error. It is our responsibility to report medication errors to aid investigation and to prevent similar errors from recurring. Step Six: Consider One or More Counterarguments Utilitarianism stresses that an act is good depending on the level of goodness that it produces. Actions are considered right if they can result to the greatest amount of happiness to the greatest number of people. If I report my colleague’s medication error, the ones who will be disadvantaged are my colleague, me, and the hospital. My colleague might face disciplinary action or termination. I might also face disciplinary action or termination for not intercepting earlier. The hospital can also receive disciplinary action from the state, aside from legal problems from the patient’s family. Also, I should be loyal to my colleague and the hospital. They are my professional “community” and they deserve my fidelity. The “winners” of reporting this incident are the patient and his family. They will know that something wrong happened, for which they have the right to, based on the justice principle. In addition, beneficence states that their welfare should come first before organizational and peer loyalty. The nurse should have also respected the patient’s autonomy regarding his medications. All in all, it seems that there will be more losers than winners if I report my colleague’s medication error. Utilitarianism deems that this action will be wrong since it will reduce the overall happiness of more people. Relativism ethics says that everyone has their own ethical beliefs and practices. One culture’s ethics should not be imposed on others. I should not impose my sense of ethics on my colleague. Her medication error might not be the cause of the patient’s death and my reporting of her errors might unjustly lead to her termination or corrective action from the hospital and/or the State Board of Nursing. Step Seven: Explore the Options for Action 1. Do nothing. I will not inform anyone regarding the mistakes of the previous nurse assigned to the patient. This will prove my fidelity to my colleague and organization. This will also show that I am not imposing my sense of morality on anyone. I will let the hospital investigate the matter and discover the true causes of death of the patient. 2. Inform the nurse trainer. I will talk to the nurse regarding what happened and ask her to document her medication error and that she withdrew pain medication in the chart. I will also ask her to report her actions to the physician and the hospital management. She might not do what I ask her though because of her fear for her job security and sense of shame. 3. Inform the doctor and the hospital. I will ask the nurse to also report her actions to the physician and management. If not, I will report her actions instead. Her previous actions can aid the investigation on the patient’s death and help determine the true causes of death. 4. Inform the patient’s family. I will ask the nurse to also report her actions to the physician patient’s family. If not, I will report her actions instead. If she can show remorse for her actions and ask for forgiveness, the family might forgive her and not press charges anymore against me. I will also inform the patient’s family about my role in this case. This will ease my guilt and show my sincerity to them that I will make sure that this same scenario will not happen again in the future. This action can also convince them to withdraw their case against me and the hospital. Step Eight: Select and Justify Action This is a difficult situation, where any action can impact my professional and personal life. Professionally, I can harm my relationship with my peers by reporting this incident and I might also receive disciplinary measures. Personally, I might experience pariah status because of exposing my peers. Still, I have decided to do what is right for the patient and not for me or my colleague or my organization. I have decided to speak to the nurse regarding her actions and to persuade her to report her past mistakes to the physician, organization, and patient’s family. I will remind her that as nurses, we have to promote our patient’s interests by following the principles of beneficence, nonmaleficence, autonomy, and justice. Also, it is part of our duties to accurately report activities, including drug administration. We have the responsibility to maintain accurate and factual medical charts. These duties are part of our nursing ethics. We should do our duties because they are the right thing to do, according to Kantianism. I will even go with her, when she reports herself to the hospital, to confirm what happened. I will also speak to the family and ask for their forgiveness for not intervening earlier and for not reporting the incident to the patient. I am truly ashamed of violating their trust and autonomy on this matter. As a nurse, my duties of beneficence, nonmaleficence, autonomy, and justice are critical to this case. In line with these principles, I should have compelled my peer to report her actions, and if not, it is my responsibility to report the medication error to the patient, physician, and hospital. I will take responsibility for the repercussions of my actions and if given the opportunity, I will help the hospital improve systems, processes, and procedures that can help reduce medication errors and assist the reporting of these errors. References American Nurses Association (ANA). (2010). Code of ethics for nurses with interpretive statements. 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