Reference no: EM133445164
CASE STUDY: ADMITTING OUR ERRORS
The nurse is caring for a critically ill client after radical neck surgery in the surgical ICU. The client is connected to a ventilator and is on a sedation protocol with continuous IV infusion of Versed, a powerful sedative that requires constant monitoring and titration to maintain the required level of sedation. During the night shift, the nurse discovers that the medication bag is almost empty, and the pharmacy, which is closed, did not send up another bag. The nurse looks up the medication and mixes the drug herself. The night charge nurse was busy supervising a cardiac arrest situation out of the ICU and was unavailable to double check how the medication was mixed.
Inadvertently, the nurse had mixed a double strength dose of the medication. Thirty minutes after she hung the new bag, the client's blood pressure was 44/20. The client required a saline bolus and a dopamine drip to stabilize the blood pressure. The family was notified that the client had taken a turn for the worse and that they should come to the hospital immediately. In backtracking for the cause of the hypotension, the nurse realizes that she had mixed the sedative double-strength and reduces the dose by half.
When the client's family arrives, the client's blood pressure has started to return to normal. They ask the nurse what happened and why their mother was on the new IV medication.
1. Should the family be told about the error?
2. Who should tell them? The nurse? The physician?
3. What approach should be used?
4. What ethical principles enter into the decision?