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Emma has started to work in a pediatric hospital as a new registered nurse in the neonatal unit with 27 beds. Nurses provide care to the newborn patients diagnosed with newborn jaundice, respiratory distress syndrome, and low birth weight. Parents are not to stay with their babies, with the exception of breast-feeding mothers, who are allowed to breast-feed in a special room twice daily. Length of stay of the newborns varies depending on the diagnosis. There are 11 bedside nurses in a unit charge nurse. Four bedside nurses in the unit charge nurse provide care to 27 newborn patients during the day shift (8-4PM) and two nurses during the evening shift (4 PM to midnight) and one nurse during the night shift (midnight to 8 AM). There is a nursing shortage problem across the entire hospital, including this neonatal unit.

 

 The hospital services are provided according to the health care, quality standards, developed by the Ministry of Health with a focus on patient employee safety. Meeting patient and employee safety and quality standards continues to be problematic, as evidenced by nursing shortages, heavy, workloads, and limited material supplies. There are differing levels of basic nursing education, with no distinction between technical and professional nursing education, and all are accepted as professional nurses according to regulation standards.

 

One day Emma came to the unit to work an evening shift after she had requisite training at the end of her second working month, and was ready to take care of the newborns together with another nurse colleague. Dayshift nurses informed Emma and her colleague that two babies have been discharged and they were 25 newborns in the unit. The unit charge nurse and two bedside nurses working in the day shift starting bedside handover by entering the newborn rooms. During baby A’s handover, Emma said in a panic “I know the babies for my previous shift and this baby is not baby A. This baby is baby B whose parent lives in another city”. Checking the identification of the newborn, they noticed that the newborns wristband showed the identity of baby B as baby A. Further investigation revealed that the nurses discharged baby A instead of baby B. One of the nurses who gave nursing care to the newborns remembered that she had changed the wristbands of the baby A and baby B because they were not readable. The unit charge nurse and Emma located the family who had baby A. After explaining the situation, the family was persuaded to bring baby A to the unit. The mistake was rectified, and the family left with their baby, baby B.

 

The nurses expressed their deep sadness and apologize profusely to the family. Fortunately, there was no permanent damage, and the family did not file a complaint. The incident was detailed in the hospital’s incident report form and forwarded to the hospital quality management department. Following the incident, the hospital nurse manager interviewed two dayshift nurses and the unit charge nurse. The hospital manager demanded a case report for their failure to recognize the correct babies and potentially created a disaster for the families. The nurses reported that they give good nursing care, however, mistakes are inevitable with a heavy workload during the shift. They expressed deep concern for their mistake and were truly sorry about the error. The unit charge nurse again mentioned heavy workload. While she was actively involved with caring for the newborns, she reinforced the inevitability of errors. The hospital nurse manager was unsympathetic and blamed the nurses, warning them, that if this occurred again, they would be punished with suspension. The hospital nurse manager praised Emma for being alert and noting the problem, which could have been a disaster. The hospital nurse manager blamed the unit charge nurse for her poor management of the nursing unit. At the end of the day, the two bedside nurses received a written reprimand, and the unit charge nurse was removed from her position. She was demoted to a staff nurse position on a pediatric surgical unit. Emma received a written recognition for her attention.

 

What are the main concerns in this case study? What patient safety goals were violated in this case study?
How would you assess the behavior of the hospital nurse manager and handling the incident? Do you believe the problem was effectively resolved and efficiently handled? If not, what would you have done differently?
Describe the problem solving and decision-making skills required as a nurse manager to solve this patient safety issue.
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