Nursing Incident: Consequences, Actions and Personal Reflection

This essay presents a case study of a nursing incident involving a fatal medication error. The incident describes a nurse who administered crushed oral tablets intravenously to a patient, leading to severe complications and death. The essay details the consequences of the nurse's actions, including a breach of duty of care and potential criminal charges. It then proposes a comprehensive nursing action plan to prevent similar incidents, focusing on improved communication, medication safety protocols, and staff training. The plan includes goals, actions, outcomes, responsibilities, and time frames for implementation. The essay concludes with a reflection on the incident, emphasizing the importance of patient assessment, adherence to protocols, and the need for nurses to seek guidance from registered nurse authorities before administering any medication. The author stresses the critical need for nurses to prioritize patient safety and adhere to established standards of care.

ESSAY INCLUDING A
PERSONAL REFLECTION

Table of Contents
INTRODUCTION...........................................................................................................................1
MAIN BODY...................................................................................................................................1
Description of the Nursing incident.............................................................................................1
Consequences of incident............................................................................................................2
Nursing action plan to improve nurse practice that prevents the incident reoccurring...............2
Brief reflection of the incident with use of points below- ..........................................................4
CONCLUSION................................................................................................................................4
REFERENCES................................................................................................................................5

INTRODUCTION
In health care facility, nursing incident can be defined as incident relates to workplace
that expose a worker or any other person to a serious risk to person health (Takeuchi and et.al.,
2019). The present report is based on the case study of Sydney grand mother who died after
nurse's error who was already at the death door. Hence, present incident took place as nurse Mrs
Lopz crushed up three differ oral tablets and put them into her IV drip and she did this without
taking anyone prior consent.
Therefore, present assignment will lay emphasies on activities as to explain nursing
incident consequences to person Mrs Anderson and their family, Nursing actions that define the
improved practice that prevents incident reoccuring. Lastly, reflection will be given about the
mistake that have been occured.
MAIN BODY
Description of the Nursing incident.
The present nursing incident was based on Sydney grandmother who died in hospital
after nurse has crushed up three different oral tablets and mix it with IV drip that was already
inserted in right hand of Mrs Anderson.
On January 27, 2009, Mrs Anderson arrived at hospital with nausea, urinary tract
infection, vomiting and dehydration. She was having the extensive medical history as high blood
pressure and server heart disease. At that night Mrs Anderson prognosis has improved and there
was talk of being released (Borhannejad and et.al., 2019). On the evening of January 30th when
Ms Lopez began her shift and crushed up three oral tablets and injected into her cannula. Within
a minute of this action taken by Mrs Lopez complained about the server pain in her arm and
wrist. Finally, at 10.35 she died, after being suffered with major heart attack.
In this case study, Mrs Anderson was in fault as she crushed up the medication without
asking from registered nurse or anyone else about this matter. Therefore, forensic report has also
showed up foreign particles in her blood and pulmonary arteries that were likely have been
binding agents from the tablets. Henceforth, these particles had obstructed the oxygenation of
Mrs Anderson's blood that contributing to her heart attack. Thus, action of the nurse warranted
criminal punishment as hotly in dispute.
1

Consequences of incident.
The act of Mrs Lopz was wrongful. She should have asked primarily to the registered
nurse authority and anyone elese about it. Henceforth, the treatmemt of Mrs Anderson's should
have diagnosed with her first so she could get know abput medication given to her. In this
incident, Mrs Anderson was administring the medication in the wrong way without checking
with anyone first.
In the Post-mortem report, from her body had found some foreign particles in blood and
some amount of plumonary arteries that were likey to have been binding adents from that
medication dose given by accused (Sullivan, 2019). Therefore, these particles had impeded the
oxygenation of Mrs Anderson blood and this contribute her to heart attrack.
Henceforth, this mistake of the Mrs Lopz has taken Mrs Anderson's to suffered a heart
attract thar caused her to death. Therefore, the medication must be given after go through the
patients treatment so proper course of medicine could be given and patient do no suffer a lot due
to mistake of others.
Nursing action plan to imporve nurse practice that prevents the incident reoccuring.
The Nurse must perform their duty of care by considering the action plan of Nursing as
are-
Goals Actions Outcome
measures
Responsibility Time Frame
To provide
medication to
patient after
diagnosing her
medical condition
with approval of
registered nurse
authorities.
Develop efficient
system that aids
to collect whole
reliable
information about
the patients'
health status.
Implement the
system that can
be utilized to
review and
communicate
safety and quality
data that can
contribute to
learning and
development.
Executive team of
Hospital
1 month
To build up the Better Executive team of 15 days
2

better
communication
system.
communication
level must be
implemented so
that health status
of the patients can
be correctly
diagnosed.
Hospital
To have
consumer
feedback to
enhance Nursing
practice.
Formal and
informal
consumer
feedback must be
utilized to
understand the
patients opinions.
Executive team of
Hospital
20 days
To implement
innovative
models of care
that ensures
efficient and
effective delivery
of quality
services.
Model of care
must be adopted
by the nursing
staff effectively
and appropriately
utilize the skills
and knowledge of
Nurse.
Executive team of
Hospital
15 days
Support Nursing
staff with training
that defines
“Nursing duty of
care”.
Build the team of
facilitators to
support the
scalability and
sustainability of
staff with
wellness
programmes.
Mindfulness,
coaching and
enabling
personalized PCC
programs have
been designed,
implemented and
evaluated (Clark,
Executive team of
Hospital
20 days
3

Polivka, Zwart,
and Sanders
2019).
Brief reflection of the incident with use of points below-
What- I have realized that Nurse should have idea about the prolonged condition of paitient
health and her treatment needs to be lookover before giving any medication. She should ask to
registered nurse authority before application of any medication.
So, what- The action of the Mrs Lopz was wrongful as she must have asked before giving any
medication (Sydney grandmother who died after nurse's error, 2015.). Afterwards, she is now
standing trial for manslaughter by gross criminal negligence a charge to which she has pleaded
not guilty.
Now what- Nurses must assess the patients conditions by checking her blood pressure level and
other vital signs. Therefore, they must perform as to coordinate with the team to plan for the
patient care. It is the responsibility of nurse to ask registered nurse authority before giving patient
any new treatment.
CONCLUSION
From the above case study, it has been analysed that the action taken by the nurse has
breached her duty of care. Therefore, Mrs. Lopez, Nurse who injected the three different
medication into her IV drip is standing for trail. Due to the wrong medication, Mrs. Anderson
Patient suffered from hearth that caused her to death. So, Nurse actions warranted criminal
punishment as “Hotly in dispute”.
4

REFERENCES
Books and Journals
Takeuchi, K. & et.al., (2019). Denture Wearing Moderates the Association between Aspiration
Risk and Incident Pneumonia in Older Nursing Home Residents: A Prospective Cohort
Study. International journal of environmental research and public health. 16(4). 554.
Borhannejad, Z. & et.al., (2019). Effect of Hospital Incident Command System Establishment on
the Preparedness Level of Disaster Committee and Nursing Staff of Imam Ali Hospital,
Zarand, Iran, 2010.
Sullivan, K. (2019). Nurse to Nursing Student Barriers and Bias. In Diversity and Inclusion in
Quality Patient Care. Springer, Cham.
Clark, P. R., Zwart, M., & Sanders, R. (2019). Pediatric emergency department staff preferences
for a critical incident stress debriefing. Journal of emergency nursing. 45(4). 403-410.
Online
Sydney grandmother who died after nurse's error. 2015. [Online]. Available through :
<https://www.smh.com.au/national/sydney-grandmother-who-died-after-nurses-error-was-
already-at-deaths-door-court-hears-20150222-13lim1.html>.
5

6