You are the unit supervisor of a medical-surgical unit.  Jane is an RN on your unit.  She graduated 3 years ago from nursing school and has made a number of small errors in the past few months, all of which she voluntarily reported.  These errors included things like missing medications, giving medications late, and on one occasion, giving medications to the wrong patient  No apparent harm has occurred to her patients as a result of these errors and on each occasion, Jane has responded to your coaching efforts with an assertion that she will be more attentive and careful in the future.  Today however, Jane came to your office to admitted that she flushed a patient’s iV line with 10,000 units of heparin rather than with the 100 units that was ordered.  The vials looked similar and she failed to notice the dosing on the label.  Jane reported the error to the patient’s physician and filled out the adverse incident report form required by the hospital on all medication errors.  At this point, the patient is demonstrating no ill effects from the overdosing but will need to be closely monitored for the next 24 hours. You recognize that Jane’s pattern of repetitive medication errors is placing patients at risk.  You have some reservations about dealing with Jane in a punitive way since she openly reports the errors she makes and because none of her errors until today ad really jeopardized patient safety.  You are also aware that you have an obligation to make sure that the staff caring for your patients are competent and that patients are protected from harm.  You are also attempting to establish a unit culture that encourages open reporting, not “shame and blame” so you are aware that your staff are watching closely how you will respond to yet another error on Jane’s part. Please answer the following questions on how you would handle the situation (5 points each) #1.  What will you do to address this error as well as the errors Jane has made in the past few months? #2.  What options are available to you? #3.  What obligations do you have to Jane, to the organization, and to the patients on your unit?

#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.