hiya! i've nearly completed my assignment and i was wondering whether someone could have a read of it. the criteria for success written below is what i need to cover in order to pass.
if you're a student nurse / rn from the uk then it'd be fantastic if you could read it and tell me where i should improve.
i'm really struggling with it so any help is very much appreciated!
- analyse and evaluate a critical incident in the care of a child with severe/life threatening illness
- critically discuss relevant developmental, ethical, legal and professional concepts
- evaluate appropriate research/evidence based findings in nursing care decisions
this assignment will analyse and evaluate a critical incident in the care of a child with severe and life threatening illness. the developmental, ethical,legal and professional concepts will be discussed critically in relation to the child and its family.
the focus of this assignment will revolve around a critical incident that occurred with regards to a child having an overdose of an antihistamine drug that was administered but not double checked and not documented.
upholding confidentiality is vital in nursing as it protects the child in question, as the nurse must treat information about patients and clients as confidential and use it only for the purposes for which it was given [...] (nursing and midwifery code of conduct 2004). therefore all names and places will be upheld in order to follow clause 5 of the nmc. consequently the patient in focus will be named 'james' to withhold his and his family's true identity.
the focus of this assignment will revolve around james, a three year old boy, his family and a critical incident that involves an incorrect dosage of an administered drug.
james and his mother came in to the accident and emergency department following an allergic reaction. james's mother had administered antihistamine prior to attending a&e, but it did not work efficiently. on arrival he was assessed by the nurse and the doctor prescribed some more antihistamine. however the doctor prescribed the medication without paying particular attention to the children's [font='times new roman']british national formulary and therefore prescribed a higher dose. the nurse did not check whether the amount prescribed was the correct dose for a child of james's weight and administered the medication. upon understanding that both the nurse and the doctor had made a critical mistake they decided to inform james's mother as he was not presenting with any abnormal clinical features following the overdose. however, it was not documented that james received a higher dose of the antihistamine medication.
this particular case presents many dilemmas, some of which are unethical and acts of negligence. benner (1984) suggests that critical incidents may range from incidents that are ordinary to those that went extremely well or those that were particularly demanding.in this case, it could have been quite life threatening as an overdose of antihistamines can cause significant autonomic and central nervous system damage (frankel et al 1993; lassaletta et al 2004) and direct cardiac toxicity (frankel et al 1993).
therefore for the purposes of this assignment there will be a focus on the legal frameworks of drug administration and the documentation in nursing. despite the fact that both nurse and doctor made an error this assignment will focus on the nurse's actions due to the word limit constriction.
firstly one has to look at how the overdose could have potentially affected james physiologically. although no clinical signs of distress occurred whilst having the overdose it is still important to understand what the effects could have been potentially. it is vital to assess james after having the overdose as it could have affected him in many ways. assessment is the first step of the nursing process. however roper et al (2004) prefer to use the term 'assessing' as a cyclical activity rather 'once-only' task (holland 2004). with regards to james, the nurse may use examination, observation and questioning. however, in order to assess him the nurse has to know what the normal values are of a child of james's age should be.
on arrival james has baseline observations conducted, and these are important as the nurse has a set of levels that she can compare with later. his heart rate on arrival was 92 beats per minute and after having the antihistamine overdose his heart rate raised to 110 beats per minute, although there is a rise after the overdose, both values are within normal parameters for his age (davies and mcquaid 1996). however, if he had had a reaction to the overdose he could have potentially become tachycardic (bnf 2006), with a possible heart rate of above 120 beats per minute, which is much higher than it should be for his age (davies and mcquaid 1996).
with an antihistamine overdose, james could have also potentially become tachypnoeic. with anaphylaxis james is already quite vulnerable in terms of his breathing as his bronchiolar can become constricted due to pulmonary edema, or swelling, which in turn can cause an increased respiration rate (sevier 2003). however as his allergic reaction was developing over a longer period it was not as serious (sevier 2003) and therefore his baseline respiration was 28 breaths per minute when assessed by the nurse, which is a normal respiratory rate for his age. although, having said that, with the overdose and the anaphylaxis, his respiration could have become more strenuous and his respiration rate could have risen to above 32 breaths per minute, which is severe for a child of his age (woodhams et al 1996).
having seen how the antihistamine overdose could have potentially affected james one has to now look at how this incident is in fact a critical incident.
when computing drug doses, nurses and doctors may make mistakes, which may be life threatening (prot et al 2005). in paediatrics it poses a unique set of risks of medication errors, predominantly because of the need for dosage calculations, which are individually based on the patient's weight, age or body surface area. this increases the likelihood of errors, particularly dosing errors (ghaleb and wong 2006). in james's case the doctor had not worked out his dose according to the children's [font='times new roman']british national formulary. also, the nurse administered the medication without double checking the dose.
in a french study by prot et al (2005) they observed 1719 administrations to 336 patients by 485 nurses. 538 administration errors were detected, and 15 per cent of these errors were dosage errors. in the findings they discussed that the pharmaceutical industry had not produced dosage forms suitable for paediatric patients. however in the uk, the children's [font='times new roman']british national formulary outlines dosages of each medication for children according to their weight. the reason as to why the doctor did not observe this is unknown, but the nurse should have questioned the dose. although james did not present with any complications as a result of the overdose the nurse should have made every precaution before administering the medication. according to the nmc's guidelines for the administration of medicines (2004) the nurse should check the right drug, dose, route, time and patient identity before administration. any unusual volumes or doses should be questioned and verified; and this did not happen with james.
much of the literature pertaining to nurses and medications draws on legal discourse, emphasizing the responsibility and accountability of the nurse in administering medications correctly and thus preventing errors (gibson 2001). [font=newbaskerville-roman]the writing of many nurses emphasises the legal consequences of errors. this can be seen in a study by morris (1999) where it summarises that if an error does occur, reporting it may enables the facility to "fix the system," and prevent similar mistakes from harming patients.[font=newbaskerville-roman] as highlighted in the nmc's guidelines for the administration of medicines, morris (1999) further states that [font=newbaskerville-roman]if the nurse follows the 'five rights' then errors would not occur. [font=newbaskerville-roman]
it was mentioned earlier that one of the reasons that james received an overdose was because the nurse had not double checked the dosage of the medication. a study by stratton et al (2004) indicated that 284 nurses that they questioned about medication errors, 28 per cent of them made these mistakes because they had not double checked the dosage. ideally no nurse should make mistakes when administering medication to patients. however, the error could have occurred due to the demanding area of an accident and emergency department. on the day that james had arrived to the department it was a busy time of the day and the nurse could have simply become distracted by other patients and their parents. conversely, in stratton et al's (2004) study, 50 per cent of the sample explained that to be the reason for making medication errors. although an accident and emergency department can become busy, this should not affect nursing care. however as indicated in stratton et al (2004) and prot et al's (2005) studies this does and can happen.
even though it does not relate directly to the critical incident, one still has to consider what the ramification of this action has upon the nurse who administered the higher dose of medication to james.
this circumstance could be classed as a case of negligence. negligence can be defined as failure to exercise the degree of care considered reasonable under the circumstances, resulting in an unintended injury to another party (hendrick 1997). this means that the nurse did not possibly intend to give the overdose to james but it could have potentially caused him harm.
all nurses have a duty of care to their patients (nmc 2004) and this includes any patient that enters the accident and emergency department (hendrick 1997).
the fact that the nurse informed james's mother that he had received an overdose can potentially place the nurse in a vulnerable position. therefore one has to ask whether the nurse did the right thing in informing on what had happened to james.
in a survey by kmietowicz (2000) it was found that nearly half the parents whose children were given the wrong treatment at that particular hospital. it was found that 56 per cent of children were given wrong treatments and although it does not mean that it is the same percentage of errors in the accident and emergency department james was in, his case highlights that it could happen.
however as the nurse understands that a patient should be informed of his care she explained the situation as it is highlighted in the one of the clauses of the nursing and midwifery council code of professional conduct (2004). in this case the nurse informed james's mother as he is not old enough to understand the effects of an overdose (bee 2000).
yet as the nurse did not document and report the incident it can have a profound effect on the nurse's career (foxcroft 2002). although the nurse informed james's mother about the incident, as it was not documented it has not occurred legally (briggs and dean 1996 / pdf file). professionally and legally the nurse is obliged to document any part of care with regards to one of her patients (nmc 2004). however this was not the case with james's incident.
[color=#231f20]record keeping is an integral part of nursing. good record keeping is a mark of a skilled and safe practitioner, while careless or incomplete record keeping often highlights wider problems with that individual's practice (nmc 2004). there is no clear reason why the nurse chose not to document and report that james had received an overdose. although there is evidence to suggest that it could be due to the fact that health professionals are afraid of the repercussion of such actions (antonow 2000)[color=#231f20].
[color=#231f20]in a survey by stratton et al (2004) when questioning nurses about why they did not report the medication errors the majority of the group did not report due to individual/personal reasons, which included nurses fearing adverse consequences from reporting and fears of losing their license[color=#231f20].
participating in the healthcare needs of the child with severe and/or life threatening illness & their families
criteria for success
[color=#231f20]in james's case the nurse it was not clear why she did not document or report despite the fact that she informed his mother.
[color=#231f20]there should be better systems in the hospital james was in for nurses to report errors without being reprimanded for their actions. the hospital that james attended encourages near miss incident reporting. they suggest that evidence demonstrates that the greatest lessons are learned from near miss incidents. the reporting of near miss incidents highlights the potential for error, or system failure, and provides the trust with an opportunity to pro-actively manage clinical risk and minimise recurrence.[color=#231f20]