Hospital: Peer ReviewApplying Rule 217.16 Minor Incidents
Read the following scenario and then answer the questions that follow
You are on your hospital's Peer Review Committee (PRC). You are reviewing Nurse A's practice. She works on the pediatric unit. In the past, Nurse A has practiced safely without incidents. However, four months ago, Nurse A gave immunizations to five pediatric patients (3 months, 9 months, 2 years, 4 years, and 5 years of age). She used a vial of Hepatitis B vaccine that had been expired for 30 days but still was being stored in the unit refrigerator. She gave the five immunizations within a few minutes of each other, and she got the vial from the refrigerator only once (i.e., She did not take it out and replace it five times). She took responsibility for the errors when she was informed by her unit manager.
Should Nurse A be reported to the BON?
Apply the Minor Incident Rule to reach and support your decision
A. Criteria. First, review your learning about minor incidents - those which are NOT reportable to the BON. In the first column of the table, list the 4 criteria that are essential in determining if an incident is not "minor."
Criteria that determine an incident is NOT minor
Explanation of whether or not the facts
determine that the incident is NOT minor
Creates significant risk of physical, emotional or financial harm to the client
There is a risk since the vaccine was expired. However, it was only by a month so the relative...
However, since it happened once, the incident is relatively minor unless verifiable injury occurred
Indicates the nurse lacks the knowledge & competencies to make appropriate clinical judgment and such knowledge and competencies cannot be easily remediated
The nurse failed to check the expiration date one time. So long as it hasn't happen other times and so long as it is engrained that it cannot happen again (i.e. the expiration date is checked BEFORE use every single time thereafter), the burden to make this a non-minor event is clearly not met.
Indicates a pattern of multiple minor incidents demonstrating that the nurse's continued practice would pose a risk of harm to clients or others.
Only one incident based on the fact that are currently known. As such, the incident is minor.
https://www.bon.texas.gov/practice_peer_review.asp
B. Minor Incident? Apply the facts of the case to each criterion above. In the second column of the table, record your explanation as to whether the facts support or do not support each of the criteria.
It is a minor incident . . . at least for this particular nurse. It is troubling that the vaccine was in the fridge for at leats a month after its expiration. Whomever has the burden to inspect and verify inventory…
