Reporting Incidents Improve Patient Safety: Administer Penicillin G Benzathine IV With Care - Essay Sample

Introduction

The reporting incidents systems improve the health of a patient. They mark and improve safety culture of a health department. The incident reports are forms that re filled to record unusual events in the health facility. The administration of penicillin G benzathine IV has been associated with cardiorespiratory arrest that causes death. Prior to administration the doctors should read the instruction, reactions and warning, and administer the medicine based on the age of the child (Howel , Burns, Hull, Mayer& seydalis, 2017). The purpose of this paper is to analyze the person, who is responsible for the death of infant baby, prevention measures to be taken in future, and develop incident tool that could evaluate the case.

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The person responsible for the death of the infant is the laboratory doctors. They feared the mother would not return with the infant thus they treated the infant before the laboratory tests results. The pharmacy had ordered to administer the medicine using the IM route but the burse failed to follow the instruction (Howel et al., 2107). They misinterpreted the information about the drugs in the reference texts and they administered the drugs by the IV route.

The incident can be prevented in future through proper following of prescribed instruction and procedure by doctors and nurses. The training the nurses and pharmacy attendants, developing team culture, and assessing the risk before administering the medicine to infant babies could prevent the incidents (Garstang, Griffiths, & Sidebotham, 2017). The nurses should administer medicines based on the age of the infant and the side effects of injecting overdose to the infant. They should learn to make proper decision that will not lead to severe outcome before making decisions about treating the infants.

The incident happened when the nurses misinterpreted the method to administer the drug to the infant that caused the death. The incident was caused by medical errors and lack of appropriate information flow from pharmacy attendant to nurses (Garstang, Griffiths, & Sidebotham, 2017). They investigated whether drug could be given intravenously where they misinterpreted the information about the drug in reference text and via oral communication from the department they administered the drug using IV route instead of IM route ordered in the pharmacy.

The nurses are responsible for reporting the incidents. They should prepare a report describing how the incident occurred and the causes of the death of the infant. The critical incidents are not caused by one person alone (Garstang, Griffiths, & Sidebotham, 2017). Reporting incidents reduces future medical errors and enables adequate flow of information in the health departments.

The incident reporting tool that can be used to evaluate this case is web- based tool known as potential error and event report systems (Garstang, Griffiths, & Sidebotham, 2017). The goal of this tool is to increase infant health safety and generating incidents reports. The incident reports will be generated by nurses through this web-based tool. It facilitates discovery, management, and reduction of adverse events (Howel et al., 2107). The nurses will give the report using web-based tool on how the event occurred in order to reduce further occurrence.

Conclusion

In conclusion, the nurses were responsible for the death of infant because they failed to follow prescribed instruction to administer the drug to the infant. The incident can be prevented by training the nurses, assessing the risks of administering drugs to the infant and developing team culture to reduce adverse events. The incident occurred due to lack of information and poor information flow from pharmacy attendants to nurses. The nurses are responsible for reporting the incident. They should use web-based tool to evaluate the case. It is efficient, accurate, and appropriate to improve the health safety of other infants.

References

Howell, A. M., Burns, E. M., Hull, L., Mayer, E., Sevdalis, N., & Darzi, A. (2017). International recommendations for national patient safety incident reporting systems: an expert Delphi consensus-building process. BMJ Qual Saf, 26(2), 150-163. https://qualitysafety.bmj.com/content/26/2/150.short

Garstang, J., Griffiths, F., & Sidebotham, P. (2017). Rigour and Rapport: a qualitative study of parents' and professionals' experiences of joint agency infant death investigation. BMC pediatrics, 17(1), 48 https://bmcpediatr.biomedcentral.com/articles/10.1186/s12887-017-0803-2