NR 544 Week 5 Accountability Case Analysis Example

Accountability Case Analysis: A Night Nurse Scans a Label Sheet Instead of a Wristband and Gives a Beta-Blocker to the Wrong Same-Surname Patient, Judged in a Stated Order Before the Outcome Is Allowed to Count

Student Name

College of Nursing, Chamberlain University

NR 544: Quality and Safety in Healthcare

Instructor Name

Month Day, Year

Accountability Case Analysis: A Night Nurse Scans a Label Sheet Instead of a Wristband and Gives a Beta-Blocker to the Wrong Same-Surname Patient, Judged in a Stated Order Before the Outcome Is Allowed to Count

The Choice, Before Anyone Knew the Ending

At 0215 on a night with one nurse short, a registered nurse on the medical unit where I work had two patients with the same surname on a five-patient assignment, in rooms 12 and 14. A rapid response had been called on a third patient ten minutes earlier, and the nurse had just returned from it. A scheduled dose of oral metoprolol was due for the patient in room 14. The nurse carried the dose into room 12, where the patient was asleep and the wristband, worn for six days, was creased and would not scan after three attempts. The nurse went to the nurses' station, opened the printed barcode label sheet kept there for unreadable wristbands, found the first label with the shared surname, scanned it, returned to the bedside and gave the dose.

That is how the decision appeared in the moment: a worn wristband, a label sheet provided for exactly that problem, a nurse under time pressure and a scheduled dose due. The analysis below judges this choice. The outcome is described afterward, because a choice judged backward from its result is not being judged at all.

The Order of the Tests

I apply three tests in a fixed order, adapted from the approach to culpability described by Reason (1997) and developed in just culture writing (Dekker, 2016). The order matters. Starting with whether a rule was broken leads directly to the individual; starting with whether a comparable colleague would have done the same leads first to the conditions of the work. I start with the second.

Test 1: Would a Colleague Have Done the Same

The comparison is to a nurse with similar experience, on this unit, at 0215, with one nurse short, after a rapid response, facing a wristband that will not scan. I asked five night nurses on the unit, without describing the outcome, what they would do. Four said they would scan the label sheet; one said they would try a new wristband first but admitted the printer for wristbands is in admitting, two floors down, and is not always stocked at night. The answer is yes: a comparable colleague would very likely have made the same choice.

Test 2: Is This the Local Normal

The label sheet is not a secret. It is printed by the unit assistant at the start of each shift and kept in a folder at the station labeled for scanning when wristbands fail. Night staff estimate that they use it several times a shift. Koppel et al. (2008) described scanning barcodes away from the patient, including from sheets of copied labels, as a common workaround to barcode medication administration, with causes that included unreadable wristbands and missing equipment, and noted that such workarounds defeat the patient check.

The shortcut is the local normal. That is a fact about how the work is designed on this unit, not about one nurse. The unit supplies the sheet, the hospital has placed the wristband printer where night staff cannot easily reach it, and the scanner accepts the label as if it were the wristband.

The comparison was not a vote on whether the choice was wise. It asked what an ordinary, competent colleague would do under the same conditions, and the answer shows that the conditions, more than the individual, produced the choice.

Test 3: Understood, and Taken Anyway

The narrowest test asks whether the nurse knew the specific risk and chose to accept it. The nurse knew, as every nurse on the unit does in general terms, that scanning a label sheet removes the check against the patient in the bed. The nurse also knew that two patients on the assignment shared a surname; the name alert was on the whiteboard. But nothing suggests the nurse recognized, at 0215, that the patient in the bed was the wrong one. The evidence points to a slip: entering room 12 while intending room 14, straight after a rapid response, and then using a practice the unit had made routine, which could not catch the slip because it checked the label rather than the person.

Staff did not regard the practice as risky, because the scanner still beeped and the record still looked complete.

The Outcome

The label scanned belonged to the patient in room 14, who did have the metoprolol order, so the scanner matched the dose to the label and raised no alert. The dose was given to the patient in room 12, who was not prescribed it. That patient's blood pressure fell from 128/76 to 102/60 over two hours and heart rate from 84 to 62. The patient was monitored, further antihypertensives were held and the patient recovered without lasting harm. The patient in room 14 missed the dose, which was recorded as given. The nurse noticed the discrepancy at 0540 while reviewing the record for room 14 and reported the error at once.

What Is Owed, Both Ways

By the three tests, the choice to use the label sheet was a behavior the unit had normalized, and the error in choosing the label was a slip under pressure, not a conscious disregard of risk. What the nurse is owed is support, a review of the event that does not treat the outcome as proof of recklessness, and coaching on checking the room number on any label used. A sanction would teach every nurse watching that reporting a label-sheet error is dangerous, which would make the practice less visible without making it less common.

What the organization owes is larger. It knew wristbands fail, supplied a sheet that removes the patient check and put the reprinting tool out of reach at night. Reason (1997) separated errors made by the people doing the work from conditions designed into a system long before; those conditions here are the sheet, the printer's location and the absence of any check when two patients share a surname. The unit should place a wristband printer on the unit, remove the label sheet or restrict it to a single patient at a time, and add same-surname pairings to the covering handoff. An analysis that stops at the nurse would leave all three conditions in place for the next night.

References

Dekker, S. (2016). Just culture: Restoring trust and accountability in your organization (3rd ed.). CRC Press.

Koppel, R., Wetterneck, T., Telles, J. L., & Karsh, B.-T. (2008). Workarounds to barcode medication administration systems: Their occurrences, causes, and threats to patient safety. Journal of the American Medical Informatics Association, 15(4), 408-423. https://doi.org/10.1197/jamia.M2616

Reason, J. (1997). Managing the risks of organizational accidents. Ashgate.