#1. To address the recent error as well as the pattern of errors Jane has made in the past few months, it is important to take a comprehensive and proactive approach. Simply relying on Jane’s assertions to be more attentive and careful in the future has not proven effective thus far. Therefore, it is necessary to implement a multi-faceted plan that addresses both the immediate consequences of the error and the underlying causes of Jane’s repeated mistakes.
First and foremost, immediate action should be taken to ensure the patient’s safety. The fact that the patient is not currently displaying any ill effects from the overdosing is fortunate, but close monitoring for the next 24 hours is essential. This can be achieved by consulting the patient’s physician and implementing appropriate interventions, such as frequent vital sign checks and laboratory monitoring.
Simultaneously, it is crucial to provide Jane with immediate support and guidance. This can begin by having a one-on-one discussion with her to understand the circumstances surrounding the medication error and to express concern for her well-being. It is important to approach this conversation with empathy and empathy, as it is likely that Jane is already feeling remorseful and anxious about the situation.
During this discussion, it is important to reiterate the gravity of the error and its potential consequences for the patient. This can help Jane truly grasp the importance of her actions and the need for improvement. Additionally, it is crucial to explore the reasons behind her pattern of errors. This can involve discussing potential causes such as distractions, workload, or gaps in knowledge and skills.
#2. Various options are available to address the situation with Jane. It is important to consider each option’s potential effectiveness in improving her performance, ensuring patient safety, and fostering a positive unit culture. Some of the available options include:
1. Remedial education and training: Provide Jane with additional education and training in medication safety, including strategies for double-checking medications and minimizing distractions during medication administration. This can help enhance her knowledge base and refresh her skills.
2. Performance improvement plan: Develop a performance improvement plan with specific goals and timelines for Jane to address her pattern of errors. This plan should be collaborative and include clear expectations, feedback mechanisms, and opportunities for support and mentoring. Regular monitoring and evaluation should be conducted to assess improvement.
3. Peer mentorship: Pair Jane with an experienced nurse on the unit who can serve as a mentor and provide guidance and support. This can enable Jane to learn from someone with more experience and help her develop strategies to prevent future errors.
4. Extra supervision: Assign an additional nurse or supervisor to closely monitor Jane’s medication administration for a period of time. This can provide an extra layer of safety and enable close observation of her practices.
5. Team debriefing and learning: Conduct a unit-wide debriefing session to discuss the recent medication error openly and transparently. This can create a learning opportunity for the entire team, allowing them to reflect on their own practices and identify system-level improvements to prevent similar errors in the future.
#3. As the unit supervisor, you have several obligations in this situation.