Narrator: Three days later, you walk down the hall and see Dr. Baird, Ena, John, and Niveda standing outside of Dr. Baird’s office. Melinda, the graduate nurse, is with them as well. You note this is before grand rounds and also see a group of nurses restocking items on one of the pediatric crash carts down the hall. They ask you to come and join their conversation.
Ena: Let’s debrief about what just happened a little while ago. Room 315 experienced a medication error that led to respiratory arrest. The patient was given the antidote and appears to be recovering, but we are going to ship her out to a higher care level to monitor for any long-lasting or recurring effects, as we do not have a Pediatric Intensive Care Unit (PICU) here. Melinda, please tell us what happened. Do not be afraid to share the whole truth. Everyone is here to support you and to see what can be done better so that this doesn’t reoccur. Everyone realizes how stressful this incident is on you, and I want to remind you that we were once all new to practice before.
Melinda: (crying and obviously upset) After I received report on the patients in room 315, I went in and performed assessments on them both.
Dr. Baird: Wait. Why were there two patients in 315? All of our rooms are private.
Ena: This is part of the new initiative that Darla has implemented. Mrs. Smith was a patient here two weeks ago, when she delivered a baby girl. Her daughter was having difficulty breathing at home so she called 911. Upon their arrival, it was found that both she and her infant had pneumonia. Darla gave permission to admit them both to the same room so that the mother and child wouldn’t be separated.
Dr. Baird: Hmm…we will discuss that later. I’m sorry for interrupting, Melinda. Please continue.
Melinda: (still very upset) After I had finished my assessments of them, I asked the mother if there was anything I could get for her. She ask for pain medication. In her report, it was noted that she did not rest all night. The orders did not have directions as to when to give which medication, so I chose to give her a dose of morphine to relieve her pain and help her rest. I gathered my supplies and the medications from the Pyxis and went to the computer to do my med check. When I returned to the room, Darla was inside doing her daily leadership rounds. I didn’t want to interrupt her, as she yelled at me in front of a patient a few days ago when I was checking their identifiers. So, I went and scanned the mother’s armband and verified her date of birth against the Medication Administration Record (MAR). It was correct. I pulled up the medication, and then Darla handed me the IV tubing…and I…I gave the mother’s medication without checking the tubing. Darla had handed me the infant’s IV tubing…not the mothers.
Dr. Baird: Let’s get someone for Melinda to talk to and to help her do the incident paperwork. Has anyone spoken with Darla?
Niveda: As soon as John and I arrived, she left…and I don’t mean she just left the room; she left the unit.
John: I have my suspicions of where she ran off to.
Dr. Baird: I do too. Ena, why don’t you and I run down to the CNO’s office for a quick chat?