Case Background
Yolanda Pinellas, a 21-year-old music conductor student, was admitted for chemotherapy, receiving mitomycin via an infusion pump. During the evening shift, the pump began to beep due to an IV dislodgment. The RN discontinued the infusion, notified the physician, and treated the infusion site. The patient, feeling groggy, recalled a nurse entering and stopping the beeping but was unsure of the details. Medical records indicated IV infiltration.
Two weeks later, Yolanda developed hand necrosis, necessitating multiple surgeries, skin grafts, and reconstruction, resulting in permanent loss of function and deformity in her fingers, impacting her ability to conduct music. The risk manager discovered that, in the three months prior, staffing issues led to many nurses working double shifts, including float nurses across various units.
The APN Roles of Administrator, Practitioner, and Educator in the Case
Administrator
Yolanda Pinellas happens to get involved in quite a gruesome encounter that permanently leaves her with some of her fingers functionless due to malpractice. Some of the administrators’ roles include overseeing the overall management of facilities, budgets, and the general staff (Chair et al., 2023). One event clear from Yolanda’s case was the case of short staffing; hence, there was no compliance with guidelines that regulate patient care. Therefore, the administrator should have been obliged to find or create policies that ensure adequate staffing for maintaining patient safety and all proper communications between the staff members, such as when the infusion fluid started.
Practitioner
In the practitioner’s case, there is constant direct contact between the families and the families in providing adequate care and support with additional education. Their prominent role is to assess their patients’ conditions, diagnose, and offer the proper treatment, hence managing those conditions. One of the ways that they perform these management techniques relates to the fact that there is a comprehensive prescription of drugs and ordering of tests (Knestrick & Russell, 2020). In the case where Yolanda was found, the practitioner might have been aware of the patient’s history and any allergies that could render specific medication harmful to her. The practitioner could also have been able to know the presence of any side effects that could arise with the infusion medication she was under to avoid the adverse reactions that led to necrosis.
Educator
The educator also played a critical role in the malpractice case, which had detrimental effects on Yolanda. Some of these roles include the factor of development and the implementation of educational programs related to healthcare providers. Other people who might also get involved in this training are the patients and their families, who offer an integrated type of healthcare.
The primary purpose of educators relates to improving patient outcomes and educating the healthcare team on best practices, new research programs, and emerging technologies (Gleason et al., 2020). However, the educator should have noted that some untrained staff members may not know how to handle infusion pumps. Some team members could also be illiterate in recognizing infiltration and dislodgment signs and responding to specific alarms.
Standards of Care Violations Pertaining to the APN Roles
Administrator
Some of the standards of care violations in the malpractice setup involve the administrator, practitioner, and educator. The administrator, in this case, violated the health care standards of practice by first failing to ensure that there was adequate staff to avoid the chances of fatigue from nurses working double shifts. Additionally, they also needed to provide proper training to the staff members regarding the safety of the patient and the right kind of communication protocols (Knestrick & Russell, 2020). Consequently, these administrators did not establish policies regarding the use of infusion pumps in the hospitals, which led to the bizarre incident.
Practitioner
The practitioner’s fail-safe mechanism regarding the standards of care involves failing to assess Yolanda’s IV site with proper monitoring of any signs of infiltration. The improper communication with Yolanda to inform her of what was happening also became problematic (Chair et al., 2023). As a result, Yolanda did not know what action to take when the infusion pump alarm went off or what to tell the nurse attending to her. Lack of documentation also served as one of the failures in standards of practice from the practitioner’s side since there needed to be a proper record of IV infiltration and the necessary action taken.
Educator
The other party involved is the educator, whose failed roles included the failure to provide adequate training with the right kind of education to the staff. The educator also needed help to elaborate on the measures of maintenance of the infusion pumps (Chair et al., 2023). The need to establish a transparent process for the ongoing evaluation with the consequent validation of the competency of the staff members regarding the use of the infusion pump also served as a primary challenge. Finally, the educator also needed to improve his role to promote a safety culture, emphasizing the importance of recording any medical errors and near-miss events.
Risk Management Steps to Be Taken Before the Incident to Alleviate the Issue
The proper actions in this case involve some risk management steps before and after the incident. Some risk management techniques include conducting an assessment regarding the staff levels. The primary reason behind this would be to ensure that an adequate number of qualified nurses always promote patient safety (Gleason et al., 2020). Secondly, there could be the implementation of a training program for all the staff members about the use of the infusion pumps and how to maintain them at all times. These include measures if the alarm goes off and the patient requires proper attention. Thirdly, there could also be the development and the implementation of policies and procedures that regard the use of evaluations with consequent validation of staff in their competency levels.
Risk Management Steps to Be Taken After the Incident to Alleviate the Issue
Some risk management procedures that would follow after the incident include conducting a root cause analysis that determines the underlying causes of the performed medical error. There could also be the implementation of reporting and tracking errors and identifying systemic causes with improvements made where necessary. Lastly, they could also develop a safety culture in the health setup to emphasize the importance of reporting medical errors and continuous improvements. Yolanda’s case, therefore, highlights one of the cases that underscore the importance of ensuring patient safety and reducing the level of medical errors through improving patient outcomes.
References
Chair, S. Y., Wong, F. K. Y., Bryant-Lukosius, D., Liu, T., & Jokiniemi, K. (2023). Construct validity of advanced practice nurse core competence scale: an exploratory factor analysis. BMC Nursing, 22(1). Web.
Gleason, K.T., Jones, R., Rhodes, C., Greenberg, P., Harkless, G., Goeschel, C., Cahill, M. and Graber, M. (2020). Evidence That Nurses Need to Participate in Diagnosis: Lessons from Malpractice Claims. Journal of Patient Safety, 17(8), pp.e959–e963. Web.
Knestrick, J. M., & Russell, N. G. (2020). Advanced Practice Nursing in the United States. Advanced Practice Nursing Leadership: A Global Perspective, 155–163. Web.