Response Prompts Instructions
Respond to at least two of your peers posts in a substantive manner. Each response needs to have a minimum of 100 words. Use the response prompts to guide your content.
- How did organizational influence, unsafe supervision, etc. cause this error to happen?
- How would you avoid making such an error in the future
MY INITIAL POST:
Harold Bennett is a 67-year-old male and is admitted to a busy hospital to undergo an elective hip replacement procedure. In the pre-operative assessment, a nurse records the patient’s allergy to penicillin on the paper intake form. Nevertheless, the hospital has recently switched to a new electronic health record system, and the allergy data is never conveyed to his electronic record because of a data migration error. Amoxicillin is an antibiotic that consists of penicillin, and it is ordered by the on-call physician, who has a 14-hour shift, as a post-surgical prophylaxis without checking the paper records. The pharmacist, who has a relatively high number of orders to handle that night, fills the prescription without indicating the allergy as the electronic system does not indicate any contraindications. The amoxicillin is given by a new graduate nurse who is not conversant with the drug relationship with penicillin and does not question the order. Mr. Bennett goes into severe anaphylactic shock and emergency resuscitation is needed within 30 minutes. This situation demonstrates how the systemic flaws, namely, the poorly designed EHR migration process, human exhaustion, lack of cross-checking, and the insufficient training of the staff formed a chain of failures that proved to be hazardous. There was no one who was entirely responsible. Rather, there were several process shortcomings that concurrently contributed to a sentinel event that was completely avoidable. Rodziewicz et al. (2024) describe this as the “Swiss Cheese Model,” where individual layer failures align to allow harm to reach the patient.
Reference
Rodziewicz, T. L., Houseman, B., Vaqar, S., & Hipskind, J. E. (2024). Medical error reduction and prevention. StatPearls. StatPearls Publishing.
PEER #1:Hello Everyone,
In healthcare settings, sentinel events often happen because of a mix of human mistakes, system problems, and process gaps. Most of the time, these events are not caused by just one error but by several issues occurring at the same time. For example, imagine a nurse working on a very busy hospital unit that is short-staffed. The nurse is responsible for several patients and is also trying to manage multiple tasks at once. One of the patients needs an IV medication at a specific dose. While preparing the medication, the nurse gets interrupted several times by phone calls, alarms, and other patient needs. Because of these distractions, the nurse accidentally administers the wrong dosage of the medication.
In this situation, human error played a role because the nurse made a mistake while preparing the medication. However, system-related factors also contributed to the incident. The unit was understaffed, which increased workload and fatigue. In addition, medication packaging in the medication room looked very similar, which made it easier to confuse two different drugs. There may also have been a lack of a required double-check system for high-alert medications.
This type of error could lead to a sentinel event if the patient experiences serious harm from the incorrect medication dose. To prevent similar incidents, healthcare organizations should improve system-level factors such as staffing levels, medication labeling, and safety protocols. Nurses can also reduce risks by carefully following the five rights of medication administration and speaking up when they feel overwhelmed. Building a strong culture of safety helps protect patients and encourages healthcare workers to report and learn from errors .
References
Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2023). Medical error reduction and prevention. StatPearls Publishing.
The Joint Commission. (2022). Sentinel event policy and procedures.
PEER#2:Hello Class,
A when looking at sentinel events we can agree that they are unexpected events that can involve harm to patients in a hospital setting that are unexpected occurrences.
A scenario I can think of is when a patient is admitted at the hospital for a surgery on their hip prior to a fall. During their stay they had surgery and had been prescribed opioid analgesics PO. The error that would be the miscommunication with the nursing staff during shift change as the patient was administered more of the medication then prescribed, being a opioid this cause the patient to overdose. The factors that we can look at is that communication between the staff prior to shift changing was not clear not only verbally but also in the patient’s chart creating a medical emergency error. The factors that contributed to this would be the documentation and lack of communication and briefing wasn’t present. Because of this, the patient goes into respiratory distress and now suffers with neurological impairments due to the lack of oxygen.
As a nurse inserting myself into this scenario, I would follow protocols like properly documenting the patients chart along with using SBAR, SOP, and PIE. which are important ways to ensure safety and that care is consistent. The SBAR is known as the Situation, Background, Assessment, and Recommendation. The SOAP is known as the Subjective, Objective, Assessment, and Plan. Then lastly, we have PIE, which is Problem, Intervention, and Evaluation. All of these highlight the core ways we as nurses implement the Nursing Process. Following and acknowledging the nursing process as I would’ve done in this patient’s case would prevent the patient from experiencing medical malpractice caused by the lack of documentation present and communication.
Hidalgo Tapia, E. C., Len Yosa, J., Olalla Garca, M. H., Clavijo Morocho, N. J., & Sanmartn Calle, Y. A. (2025). Effectiveness of Nursing Documentation Frameworks (SBAR, SOAP, and PIE) in Enhancing Clinical Handoffs and Patient Safety. Cureus, 17(8), e89957.
PERSONAL PHILOSOPHY OF NURSING PRACTICE