Discussion response

In the chemotherapy infusion room, there was a patient receiving what he thought to be his final dose of chemotherapy. However, the nurse providing care for him noticed that his height was incorrect in the electronic medical record (EMR) that the hospital had switched to five months ago. Instead of stating six feet, it had his height being four feet. It turned out he had been underdosed throughout his treatment. Instead of being done, he now had to receive two more cycles to make up for underdosing the chemotherapy. The patient was understandably upset and scared that this might impact his outcome. In light of this event, administration changed policy that every patient was required to have a new height measurement performed when they came for infusion.

Regulatory Decision Pathway

There are four types of behavioral choices, they are human error, at-risk behavior, at-risk behavior, and deliberate behavior (Russell & Radtke, 2014). This situation seems to best align with human error. The nurses were on a relatively new EMR system and assumed the height had been correctly inputted by the first nurse. The rates of medication errors in an outpatient infusion setting was found to be 8.1 errors per 100 clinic visits. Chemotherapy agents usually have a narrow therapeutic index and are administered in complex, multidrug regimens. They usually include frequent adjustment due to renal function, toxicity, and other clinical parameters. Error-prevention strategies should be applicable to the settings where these chemotherapy agents are used (Goldspiel et al., 2015).

A well-designed system should promote shared accountability and embrace the multifaceted relationships of consoling human error, coaching at-risk behavior, and punishes reckless or malicious behavior (Pepe & Cataldo, 2011). In “just culture” administrators try to answer whether a medical error deserves forgiveness and restoration, or demands retribution and sanction (Dekker & Nyce, 2013). In this instance, I feel this approach is to forgive and restore. The nurses were not punished individually, instead an action plan was created to prevent the error from happening again. As a result of the incident all the nurses became more careful and verified height and weight of the patients that they were accurate.

References

Dekker, S. & Nyce, J. (2013). Just culture: “Evidence, power and algorithms. Journal of

Hospital Administration, 2(3), 73-78. Retrieved from

http://sidneydekker.com/wp-content/uploads/2013/01…

Goldspiel, B., Hoffman, J., Griffith, N., et al. (2015). ASHP guidelines on preventing

medication errors with chemotherapy and biotherapy. American Journal

Health-System Pharmacists, 72.

Pepe, J. & Cataldo, P. (2011). Manage risk, build a just culture. Health Progress.

Retrieved from

http://www.outcome-eng.com/wp-content/uploads/2012…

Russell, K. & Radtke, B. (2014). An evidence-based tool for regulatory decision-making:

regulatory decision pathway. Journal of Nursing Regulation, 5(2), 5-9.

Can you please respond to this discussion post. APA format, at least 5- 10 sentences. 2 references