Critical Thinking Exercise 2

Incidental Finding

Lindsey Grey was a registered nurse at Quinbery General Hospital. She had been working numerous shifts to cover hours for several vacant positions.Lindsey was a single mother of a little girl, Missy; a child with developmental disabilities. Lindsey was new to the community, so she had no friends or family to help in times of need.

Sunday morning, Lindsey was looking forward to going home after work and spending the day resting and playing with Missy. Next thing she knew, two of the day shift nurses called in sick and Lindsey was asked to cover for one of the RNs. She needed the money, so she decided to cover the shift. Things were very quiet and uneventful until about 2:00 pm. One of her patients, Joseph Johnson, was found unresponsive and a code blue was called. Lindsey was a very good nurse but the fatigue of long shifts and little sleep were not allowing her to think coherently.

Mr. Johnson had developed bradycardia. The physician, Dr. Michael Benjamin, a cardiac specialist responded to the call. He requested atropine.Inadvertently, Lindsey grabbed the vial from the crash cart, reading the label from the vial next to the one she grabbed: lidocaine. She drew up the ordered amount and handed it to Dr. Benjamin. The patient s condition worsened. A second order was given and again Lindsey drew up the ordered amount and handed it to the physician. Lindsey replaced the vial to the crash cart, and when the physician requested the medication the third time, Lindsey realized she had possibly made a mistake. Mr. Johnson became unresponsive and after several attempts at CPR, he was pronounced dead. In the excitement of the event, Lindsey was unable to tell the Dr. Benjamin what she suspected.

After speaking with the family, Dr. Benjamin was approached by Lindsey and she explained what she believed had occurred. An incident report was written and in the rush was filed on the patient s chart instead of being sent to Risk Management. What Lindsey and Dr. Benjamin did not know is that one of Mr. Johnson s relatives, Larry Lincoln, had overheard their conversation.

A week later the patient s family contacted an attorney and a subpoena duces tecum was sent to the hospital for copies of Mr. Johnson s chart. Cynthia Myers, the release of information specialist, was on vacation, so Sandy Silvers, a second shift HIM clerk, received the request to retrieve the records, make copies, and prepare it for the lawyer s office. Since Sandy had only been working three months in the department, she had never seen an incident report before, and did not know where to file it. Since no supervisor was available, she filed it into the chart behind the Miscellaneous tab. Later that day, a copy of Mr. Johnson s chart was delivered to the lawyer s office

QUESTIONS