Case 5 Incidental Finding: Janet Lewis Was A Registered Nurs

Case 5 Incidental Findingjanet Lewis Was A Registered Nurse At Hillsid

Janet Lewis was a registered nurse at Hillside Community Hospital. She had been working numerous extra shifts to cover hours from vacant positions. On top of that, she was a single mother of a child with developmental disabilities, which frequently left her exhausted. Janet had no family to assist her, and she was new in town. Her work schedule did not allow time for socializing, so she had not yet established any close friends to help in times of need.

Saturday afternoon, Janet was looking forward to going home after working 72 hours that week; she had just three more hours until she could go to bed. Next thing she knew, two of the second shift nurses called sick, and Janet agreed to cover for one of them. The shift was relatively quiet and uneventful until one of Janet's patients was found unresponsive in his room: a code blue at the end of her shift. Janet normally reacted very well in these situations, but she was barely coherent from lack of sleep. The patient had developed severe bradycardia.

The physician attending the call requested atropine. Janet was having trouble focusing, so she asked the physician to clarify; again, atropine was requested. She grabbed a vial from the crash cart, inadvertently reading the label from the vial next to the one she grabbed: lidocaine. She drew up the ordered amount and handed it off to the doctor. The patient's condition worsened.

The physician demanded more atropine. Janet was still holding the lidocaine vial and proceeded to dispense the ordered amount. Janet replaced the vial on the crash cart, when the physician ordered additional atropine. She grabbed the vial labeled as atropine and dispensed to the physician. It was at this point that Janet realized she possibly had the wrong medication previously.

However, in the hectic moment of the code, she hesitated to inform the physician. After additional resuscitative measures were attempted, the code was called, and the patient was pronounced expired. The physician spoke with the family immediately after the code, and then they went into the room to view the expired patient. Janet approached the physician when he returned to the nurses' station to complete his documentation. She explained that she possibly gave him the incorrect medication.

An incident report was completed, and in the rush, it was filed on the chart instead of being sent to Risk Management. What Janet and the physician did not know was that a member of the patient's family, who was leaving, overheard the conversation but did not address it with Janet or the physician. Carla was new to the health information management field and was working in her first “real” job at Hillside Community Hospital as an Assembly and Analysis Clerk. She had been in her position for six months and was competent in her work. She occasionally encountered unfamiliar documents and generally asked questions when she found forms that could not determine where to file.

Carla worked second shift on Sunday night when she got to the chart with Janet's incident report. She was the only person covering the office on Sunday evenings. When Carla stumbled on the incident report and did not have anybody to ask about it, she simply filed it behind the miscellaneous tab because her trainer failed to mention anything about sending incident reports to Risk Management. The following week, the patient's family contacted an attorney and presented the hospital with a malpractice lawsuit. A subpoena was sent for copies of the record.

The Release of Information Specialist had an unexpected family medical emergency, so others in the department were covering the position. Carla had volunteered to work extra hours and was helping prepare records for release of information. Still unaware that incident reports were not to be part of the medical record, Carla included Janet's incident report in the copies, and they were delivered. Jose, the Director of Health Information Services, was on vacation during this time. Because Hillside Community Hospital had a small Health Information Services department, there were not any Assistant Director or supervisors.

The subpoena required that copies of the records be delivered in person to the Hillside courthouse, so Jose had Carla take them.

Paper For Above instruction

This case highlights the multifaceted responsibilities and potential pitfalls associated with healthcare professionals and hospital administrative staff, emphasizing the importance of proper actions, awareness of legal and ethical standards, and the influence of internal and external forces on patient safety and legal liability.

Analysis of Actions That Could Have Reduced Risk

Each individual involved in this case could have taken specific actions to mitigate risks and improve outcomes for Hillside Community Hospital. Janet Lewis, the nurse, could have enhanced her medication verification process, especially under stressful conditions. Utilizing the "read-back" technique, where she repeats the medication name and dose to the physician, would have reduced chances of error. Furthermore, double-checking labels before drawing medication, particularly during critical moments such as resuscitation, is crucial. Training and adherence to medication safety protocols, such as barcode scanning (if available), could prevent such errors. Additionally, Janet should have promptly reported her suspicion regarding the medication error to the physician and risk management, rather than hesitating during the code, to prevent further deterioration of patient safety.

The physician also bears responsibility for verifying medication and ensuring correct administration, especially when requesting multiple doses. They could have explicitly confirmed the medication being dispensed, which could have triggered a clarification process. Comprehensive training in medication safety and awareness of the risks associated with handoffs and hectic clinical situations is essential for all healthcare providers.

Carlas’s role in the documentation process indicates gaps in hospital policies and staff training. She could have sought clarification on the proper procedure for incident reports, knowing that these reports are intended for risk management rather than the medical record. Instituting standardized procedures for incident report handling and ensuring staff are trained in confidentiality and legal boundaries would have prevented the inclusion of incident reports in patient records.

Internal and External Forces Impacting the Case

Internal forces include hospital policies, staff training, and organizational culture. The absence of clear procedures for incident report handling and limited staff supervision led Carla to file the report incorrectly. The hospital’s small size and lack of supervisory personnel may have contributed to insufficient oversight and accountability, increasing the risk of procedural errors. Additionally, the high-stress environment during emergencies like codes can cause lapses in standard procedures, affecting patient safety.

External forces involve legal, regulatory, and societal influences. Legal liabilities such as malpractice lawsuits and subpoenas for medical records create pressures on healthcare providers and administrators. Regulatory standards like those from The Joint Commission mandate specific procedures for medication safety and documentation, which hospitals must adhere to to maintain accreditation. Societal expectations for patient safety and confidentiality also shape hospital policies. Furthermore, external advocates and media can influence hospital practices and accountability through increased scrutiny and public awareness.

Legal Issues Addressed in the Case

The case raises multiple legal issues, primarily centered on medical malpractice and record-keeping responsibilities. The primary concern is the potential harm caused by medication error during the code blue, which could be grounds for negligence claims if proven that the hospital failed to implement safe medication administration protocols. The improper handling of incident reports and unauthorized disclosure of protected health information (PHI) by including them in patient records breaches confidentiality and violates HIPAA regulations. The unauthorized release of incident reports in response to a subpoena further complicates legal liability, risking non-compliance with privacy laws.

Moreover, the hospital's failure to train staff properly on incident report procedures and the lack of adequate supervision during record preparation expose them to potential legal repercussions. The legal implications also encompass the hospital’s liability in case of delayed identification of the medication error and steps taken afterward, including documentation and communication.

Ethical Issues Addressed in the Case

This case presents several ethical dilemmas. First, the decision of Janet to hesitate in reporting the medication mistake raises concerns about honesty and duty of care, fundamental to nursing ethics. Her reluctance could be attributed to fear of repercussions, highlighting ethical conflicts between transparency and fear of punishment. The physician’s failure to verify medication details during a critical scenario also presents an ethical lapse concerning patient safety and duty of diligence.

Additionally, Carla’s mishandling of the incident report and acting without proper guidance infringes on ethical principles related to confidentiality, accuracy, and professional accountability. The inclusion of incident reports in the medical record without proper authorization violates patient privacy and breaches ethical standards for health information management.

The broader ethical issues involve balancing the confidentiality of incident reports against the need to report and resolve medical errors, emphasizing transparency and accountability. The hospital staff’s actions must align with principles outlined in the American Health Information Management Association (AHIMA) Code of Ethics, which emphasizes integrity, confidentiality, and professional responsibility.

How the AHIMA Code of Ethics Covers These Ethical Issues

The AHIMA Code of Ethics underscores the importance of maintaining confidentiality, integrity, and professional responsibility. Regarding confidentiality, the Code mandates that health information professionals protect patient privacy and only disclose information as authorized or required by law. The mishandling of incident reports—filed in the medical record and shared with the court—contradicts these standards, and staff must be educated on proper procedures.

In terms of integrity, AHIMA emphasizes honesty and accountability in all actions. Janet’s hesitance during the code and Carla’s unauthorized inclusion of the incident report breach this principle, indicating a need for ongoing training and ethical culture development. The case illustrates the importance of professionals adhering to ethical standards to prevent harm and legal repercussions, reinforcing the role of ethical behavior in healthcare information management.

Evaluating Possible Actions and The Best Course

Considering all stakeholders and risks, the hospital should implement comprehensive staff training focused on medication safety, incident reporting procedures, and the importance of respecting patient privacy. Establishing clear protocols for documentation, especially regarding incident reports, would prevent future mishandling. Regular audits of staff adherence to these protocols and fostering a culture of transparency would mitigate ethical dilemmas and legal risks.

The hospital administration should also review and reinforce policies regarding the confidentiality of incident reports, ensuring that only designated personnel handle such documents and that their handling complies with legal standards. Implementing robust electronic health records with barcode medication administration and automated alerts could prevent medication errors. Additionally, providing support and monitoring for healthcare staff working extended hours can reduce fatigue-related errors, as seen in Janet’s case.

In terms of addressing the immediate aftermath, the hospital should conduct a root cause analysis to understand the error during the code and develop targeted training. They also need to establish a clear legal and ethical framework for handling subpoenaed records, ensuring all disclosures are compliant with privacy laws and hospital policies.

The most effective approach is a multipronged strategy: enhancing staff training, reinforcing policies, leveraging technology for medication safety, and fostering an organizational culture dedicated to transparency and continuous improvement. This comprehensive plan not only reduces legal and ethical risks but also improves patient safety and trust in the healthcare system.

Conclusion

This case underscores the critical importance of proper communication, documentation, and adherence to legal and ethical standards in healthcare. By adopting standardized procedures, investing in staff education, leveraging technology, and cultivating a culture of transparency, Hillside Community Hospital can reduce the risk of medical errors, protect patient privacy, and strengthen its legal standing. Ultimately, a proactive and ethically grounded approach contributes significantly to safer patient care and organizational integrity.

References

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• American Health Information Management Association. (2013). Code of Ethics for Health Information Professionals. AHIMA.
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