Identify a problem from an error or mistake
The problem to identify as an error is when a chemotherapy regimen was hung by the evening night at 10:00pm. Hand off report given at 12midnight. Both nurses
identified the amount of chemotherapy left in the bag at the change of shift. At 4am, a call was received from the night nurse to the evening nurse stating the
chemotherapy infusion was empty. Unsure how this occurred when the evening nurse verified the infusion with the incoming nurse. Instead the evening nurse was accused
of the error and detail to another department away from patent care until the investigation was completed. During the investigation the night nurse decided to
“continue to defend her story” that hand off report was done per the policy. Instead of charging the error on both nurses. The evening nurse was left to hire a lawyer
in her defense. The summary of the story; the evening nurse was accused of the error and the lawyer she hired found the error should been placed on the night, since
she did not assess the veteran until 5am in the morning, oppose to the beginning of the shift. The evening nurse received 3 witnesses from the evening shift that they
heard and saw both performed bedside hand-off report. This brought awareness to the importance of providing and verifying hand-off report on each shift.
•Articulate a plan of action to improve the problem in the identified environment.
An electronic hand-off template was developed with electronic signature to be provided from incoming and off-going nurse.