Critical Incident Review

Sample Solution

Critical Incident Debriefing Example

Scenario: A nurse accidentally administers the wrong medication to a patient. Thankfully, the mistake is caught before it has any serious consequences.

Debriefing:

1. Introduction:

• Briefly explain the purpose of the debriefing - to discuss the recent medication error, identify contributing factors, and prevent future occurrences.
• Establish a safe and confidential space for open communication.

Full Answer Section

2. Fact-Finding:

• What medication was administered incorrectly?
• What was the intended medication?
• How was the error discovered?
• Were there any near misses or adverse effects?

3. Thought Phase:

• What was the nurse thinking during the medication administration process?
• Were there any distractions or interruptions?

4. Reaction Phase:

• How did the nurse feel upon realizing the error?
• How did the patient react to the situation?

5. Symptom Phase:

• Did the nurse experience any physical or emotional symptoms (stress, anxiety) after the incident?

6. Teaching Phase:

• Review medication administration protocols and safety measures.
• Discuss strategies to prevent similar errors in the future (double-checking, asking for verification).
• Provide resources for stress management and emotional support.

7. Re-Entry Phase:

• Develop a plan for the nurse to return to their duties with confidence.
• Offer ongoing support and identify who the nurse can approach if they have concerns.

• Throughout the debriefing, emphasize patient safety and ethical practice.
• Use a blame-free approach - focus on learning and improvement.

• The debriefing should lead to a clearer understanding of the medication error and how to prevent similar incidents.
• The nurse should feel supported and equipped to continue their duties safely and ethically.
• The healthcare facility should identify any systemic issues that contributed to the error and take steps to address them.