Reporting Incidents
The reporting incidents systems improve the health of a patient. They mark and enhance the safety culture of the health department. The incident reports are forms that are filled with a record of unusual events in the health facility. The administration of penicillin G benzathine IV is associated with a cardiorespiratory arrest that causes death. Before administration, the doctors should read the instruction, reactions, and warning, and administer the medicine based on the age of the child (Howell, Burns, Hull, Mayer& Seydalis, 2017). The purpose of this paper is to analyze the person, who is responsible for the death of an infant baby, prevention measures to be taken in the future, and develop an incident tool that could evaluate the case.
The person responsible for the death of an infant is the laboratory doctors. They feared the mother would not return with an infant; thus, they treated the infant before the laboratory tests results. The pharmacy had ordered to administer the medicine using the IM route, but they failed to follow the instruction (Howell et al., 2107). They misinterpreted the information about the drugs in the reference texts, and they administered the drugs by the IV route.
An incident can be prevented in the future through proper following of prescribed instruction and procedure by doctors and nurses. It can be prevented through training nurses and pharmacy attendants, developing team culture, and assessing the risk before administering the drugs on infant babies could prevent the incidents (Garstang, Griffiths, & Sidebotham, 2017). The nurses should administer medicines based on the age of the infant and the side effects of injecting overdose to an infant. They should learn to make the proper decisions that will not lead to severe outcomes before making decisions about treating the infants.
An incident happened when the nurses misinterpreted the method to administer the drug to the infant that caused the death. The event is caused by medical errors and a lack of proper information flow from pharmacy attendants to nurses (Garstang, Griffiths, & Sidebotham, 2017). They misinterpreted the information about a drug in reference to the text and via oral communication from the health department. They administered the drug-using IV route instead of the IM route ordered in the pharmacy.
The nurses are responsible for reporting the events. They should prepare a report describing how the incident occurred and the causes of the death of the infant. The critical incidents are not caused by one person alone (Garstang, Griffiths, & Sidebotham, 2017). Reporting incidents reduce future medical errors and enable an adequate flow of information in the health departments.
The incident reporting tool to evaluate this case is an incident report form(Garstang, Griffiths, & Sidebotham, 2017). It facilitates the discovery of the causes of death of the infant and the reduction of adverse events. It will evaluate the case and increase infant health safety, and generating incidents reports reduce the further occurrence (See figure 1 for incident report sample).
In conclusion, the nurses were responsible for the death of an infant because they failed to follow prescribed instructions to administer the drug to the infant. The incident is prevented through training the nurses, assessing the risks of delivering medication to the infant, and developing team culture to reduce adverse events. The incident occurred due to a lack of information and poor information flow from pharmacy attendants to nurses. Nurses will generate incident reports. They should use incident reporting form tools to evaluate the case because it is efficient, accurate, and appropriate to improve the health safety of other infants.
Incident report form information
Reported by__________________ Date of report_____________
Incident Number._________________
Incident type: Death of new born infant
Date of the incident and the specific location_________________
Incident Description
The death of new born infant occurred after the infant was given penicillin G benzathine IV using IV route instead of IM route. The nurses misinterpreted the information about the drug in the reference texts and via oral communication with health department.
Role of parties involved
The parties involved are doctors, nurses, and pharmacists who are responsible for treating the newborn infant. The nurses were responsible for administering the drug to the infant. The pharmacist gave nurses instructions on how to apply the medication to the infant.
Follow up action.
The incident is to be followed up by health professionals in the hospital where the infant died.
Signature from health department officer______________________
References
Howell, A. M., Burns, E. M., Hull, L., Mayer, E., Sevdalis, N., & Darzi, A. (2017). International recommendations for national patient safety incident reporting systems: an expert Delphi consensus-building process. BMJ Qual Saf, 26(2), 150-163. https://qualitysafety.bmj.com/content/26/2/150.short
Garstang, J., Griffiths, F., & Sidebotham, P. (2017). Rigour and Rapport: a qualitative study of parents’ and professionals’ experiences of joint agency infant death investigation. BMC pediatrics, 17(1), 48 https://bmcpediatr.biomedcentral.com/articles/10.1186/s12887-017-0803-2