Moreno Medical Center from Patient’s Perspective

Selected Incident

Careful monitoring of patients’ condition is an integral task of medical staff. At the same time, nurses must monitor specific cases and provide appropriate care. The tasks of the management of medical institutions are to control the junior medical personnel’s activities and to prevent potential mistakes in work.

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One of the incidents that deserve attention is an overdose of an incorrect drug. Instead of morphine, overwhelming pain, one patient took hydromorphone by mistake, which caused respiratory arrest. The timely interference of resuscitators’ team allowed quashing the effects of this error quickly. The patient was not seriously injured, and the consequences of this nursing error did not arise.

Manager’s Observations Concerning the Incident

The task of medical organization’s leader is not only to manage a particular clinic or center but also to supervise the work of subordinates and to ensure that all duties are carried out in strict accordance with the job description. A nurse manager is a person who regulates the activity of junior medical personnel and ensures that these employees competently fulfill doctors’ prescriptions and provide patients with the necessary care. The better the quality of care, the more likely that patients will recover faster and feel good (Hospital visitation policy, 2017).

What concerns the described incident with an erroneous drug, the responsibility lies not only on those employees who used the wrong medicine but also on the nurse manager. The thing is that the task of this person is not just to assess the performance of his or her subordinates but also to prevent any, even the most unexpected situations (Nursing care center, 2017). If the hospital staff had been more attentive, this case would not have happened.

Therefore, the manager of nurses should conduct timely work with the team and ensure that entirely all working moments are performed competently and responsibly. The patient’s perspective is the most important determinant of whether an adverse event has occurred because the degree of seriousness of the medical error directly affects people’s health and well-being. The more dangerous the mistake of medical personnel is, the less likely that the patient will be able to bear its consequences easily.

Nurse Manager’s Preventive Measures

First of all, it is necessary to conduct explanatory work with the staff about how dangerous is the replacement of medicines and what consequences such an error can bring. It is also essential to consider the incident in detail and discuss its nuances with the staff (The purpose of risk management in healthcare, 2017).

Nurses’ opinions should be listened about why this situation occurred and why all the employees did not notice that the medicine that the patient took was completely different. After listening to all the explanations, it is necessary to conclude for what reason the violation occurred: whether it was a negligence of any of the nurses or several people were guilty.

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Next, it is significant to mention the possible negative consequences of such an error. According to Schneider et al. (2014), if employees know what consequences medical errors can entail, they will probably be more attentive in the performance of their immediate job duties. Also, there is a need to discuss what measures should be taken to ensure that such a situation will not happen again.

First, the nurse manager should tighten control over the storage of potent drugs. Secondly, it is possible to notify nurses that responsibility for the medicines given to patients rests with them, and in case of similar incidents, they will surely have problems. Such an algorithm of actions is complicated enough. However, it is perhaps the only way to ensure that the previously described case will no longer happen again, and all staff will be aware of the possible consequences of such errors.


Hospital visitation policy. (2017). Web.

Nursing care center. (2017). Web.

The purpose of risk management in healthcare. (2017). Web.

Schneider, E. C., Ridgely, M. S., Meeker, D., Hunter, L. E., Khodyakov, D., & Rudin, R. S. (2014). Promoting patient safety through effective health information technology risk management. Rand Health Quarterly, 4(3), 7-22.

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