Medical error in post-cesarean oxytocin administration and nursing accountability

¶ … Beyond the critical incident itself, which will be described and looked at as part of this report, I will also bring in a number of major themes and analysis methods. The two major tools that will be used in this report are Carper's Fundamental Patterns of Knowing and Gibb's Reflective Cycle. Each step and part of those two frameworks will be looked at in fairly strong detail. The essay will end with a conclusion that encapsulates and summarizes all the main points made throughout the report.

Coming back to the incident itself, the incident will not name the hospital or any of the people involved but the incident will be described with a strong level of detail. The details will include the problem that occurred, what led to the problem occurring, how the incident came about and climaxed and the resolution to the problem will be discussed at the end. I will also offer a solution that would have perhaps headed off the problem to begin with as there was a clear lack of quality control and double-checking and this can lead to the death of a patient if it happens to excess and/or at the wrong time. This can even be true in situations where life and death is not the initial problem as the critical incident in this case surrounded a woman who had just had a C-section baby delivery and was not at risk of dying or any other major complications until she had an unhealthy dose of Oxytocin IV.

Chapter II - The Critical Incident

The critical incident for this report involves a patient who had just come from an operating room after receiving a cesarean section. Incident to the surgical delivery, the patient was receiving intravenous oxytocin per the recovery nurse. Subsequent to that, I checked the system for any new orders and the patient's medications list. I found that oxytocin IV still appeared on the system as a regular dose. When the pre-existing bag was finished, I started a new bag as the order still active on the system.

The doctor started doing rounds and a consultant asked me if the Oxytocin bag with attached to the patient was the same one present when surgery ended. I informed the consultant that it was actually a second bag because the order was still active in the system when the first bag ran out. The consultant then shouted loudly and he asked me to stop it immediately because the order should have been given as one dose after delivery. I was surprised and troubled because our actions may have led to several complications to the patient. Just as one example, the uterus of the patient could have ruptured.

I asked myself internally why the order was still on the system. However, I also did not ask for clarification. The good thing was that I responded to the consultant order immediately without any delay. Fortunately, nothing negative happened to the patient. The bad thing about the situation is that I did not ask the recovery nurse if the initial bag was to have been the last dose. I checked all the orders carefully before the recover nurse left. I feel that both the nurses and the doctors made mistakes. The assistant consultant did not cancel the order from the system and this means that the medication is to be given regularly and not as a stat dose only for one time.

Chapter III -- Gibb's Reflective Cycle

Gibb's Reflective Cycle can and should have been applied to this situation. There are six steps to the Gibb's Reflective Cycle. They occur, as noted by the title in a cycle or circle and the process is ongoing. The steps are description, feelings, evaluation, analysis, conclusion and action plan. A description would be an honest and complete description of what occurred. This is what I did above. The feelings would be what the person involved in the event was thinking or feeling. I was upset that an error was made even though it was not initially my fault. The evaluation state is what was good and bad about the experience. It was eventually good that I learned from the event but the event itself was obviously bad. The key for me was to learn from the event. The analysis component asks me what sense can be made of the situation. I analyzed what happened and why. The conclusion is what else could or should have been done relative to the situation. This was done by me when I planned how to avoid the happenstance in the future. This leads to the last step, which is the action plan. This is what would be done if the event happened again in the same or a similar way (Fakude & Bruce, 2003).

To apply this to the critical incident that happened earlier in this paper, a lot of this was already noted in the critical incident description but will be done again and it will be much more drawn out. The description of the event is fairly basic. The patient who had just had a C-Section had been given a bag of Oxytocin IV that should have been a single bag that was not repeated with a second or further bag of the drug. A doctor should have ensured a second bag was never used. Since the order was still active in the system, I gave a second bag to the patient. This turned out to be the wrong move because too much Oxytocin can lead to uterine rupture, overdose and many other very nasty things. I was in distress that I was the least bit involved in the administration of a dose that was potentially damaging or even lethal to the patient. However, there were also feelings of relief for me because the mistake was caught early on and the patient ended up not being harmed and probably completely unaware that it happened in the first place. The consequences of this accident could have been expansive and wide-ranging. If the new mother had died or become severely injured, it would have been a burden on her (if she lived), her child and her extended family. The hospital itself would have likely been liable for the death and would have to pay a large amount of money to the family of the mother. Any medical staff member that had a responsibility to add or remove the Oxytocin order would face reprimand or even termination and/or legal liability.

An evaluation was done and there were two major issues. First, the doctor should have removed the order for the medicine after first bag was put in place and I should probably know that a single bag of Oxytocin is the norm. Even if there are sometimes deviations from this or any other norm, the nurse should have asked just to be sure. If either of those had been done here, the second bag would have never been added and the mistake would have been avoided. I can absolutely make sense of the situation and realizes that even though the doctors are higher than the nurses, mistakes can still be made and it's not wrong to ask questions. All the things that could have been done are noted above (conclusion) and I will make sure to ask questions next time if there is any doubt in my mind and the safety and comfort of the patient is at risk. Nursing and medicine are fields that absolutely call for and demand internal review and improvement of process. The Gibbs Reflective Cycle does not replace being light on one's feet and being able to react at the time rather than always after the fact (Fakude & Bruce, 2003). However, the cycle absolutely facilitates what can be done proactively rather than reactively so this is a good thing about the framework and methodology behind it. It is good practice for any nurse or doctor to use this methodology.

Conclusion

In the end, I feel better about the critical incident because nobody was hurt (although the person absolutely could have been hurt) and some major lessons were learned. This will help me in the long run and will help lead to prevention of issues like this coming up in the future. Being precise and careful in medicine is imperative. It should not be about egos or stepping on anyone's toes. This is especially true for someone that has clearly made mistakes in the past and these mistakes are potentially harming or lethal in nature. The Carper and Gibbs frameworks are both very informative and enlightening when thinking about this critical incident and the future implications that this prior event will have. Using these frameworks clearly allowed me to take theory and my real life experiences and really learn something good. I actually reached the proper conclusions before stumbling across these frameworks but the frameworks did drive home the idea that I came to the right conclusions and that my plan of action for the future is sound and well-minded. It is reassuring that there was not a huge disconnect between the process or the proper outcome between what I came to and what the Gibbs or Carper frameworks would suggest that I come to. However, I do see the possibility that other people would come to slightly or majorly different conclusions but this should not be the case for most people. The doctor clearly made a mistake by not removing the Oxytocin order but I could have stopped it and that does matter.