¶ … Beyond the critical incident itself, which will be described and looked at as part of this report, I will also bring in a number of major themes and analysis methods. The two major tools that will be used in this report are Carper's Fundamental Patterns of Knowing and Gibb's Reflective Cycle. Each step and part of those two frameworks will be looked at in fairly strong detail. The essay will end with a conclusion that encapsulates and summarizes all the main points made throughout the report.
Coming back to the incident itself, the incident will not name the hospital or any of the people involved but the incident will be described with a strong level of detail. The details will include the problem that occurred, what led to the problem occurring, how the incident came about and climaxed and the resolution to the problem will be discussed at the end. I will also offer a solution that would have perhaps headed off the problem to begin with as there was a clear lack of quality control and double-checking and this can lead to the death of a patient if it happens to excess and/or at the wrong time. This can even be true in situations where life and death is not the initial problem as the critical incident in this case surrounded a woman who had just had a C-section baby delivery and was not at risk of dying or any other major complications until she had an unhealthy dose of Oxytocin IV.
Chapter II - The Critical Incident
The critical incident for this report involves a patient who had just come from an operating room after receiving a cesarean section. Incident to the surgical delivery, the patient was receiving intravenous oxytocin per the recovery nurse. Subsequent to that, I checked the system for any new orders and the patient's medications list. I found that oxytocin IV still appeared on the system as a regular dose. When the pre-existing bag was finished, I started a new bag as the order still active on the system.
The doctor started doing rounds and a consultant asked me if the Oxytocin bag with attached to the patient was the same one present when surgery ended. I informed the consultant that it was actually a second bag because the order was still active in the system when the first bag ran out. The consultant then shouted loudly and he asked me to stop it immediately because the order should have been given as one dose after delivery. I was surprised and troubled because our actions may have led to several complications to the patient. Just as one example, the uterus of the patient could have ruptured.
I asked myself internally why the order was still on the system. However, I also did not ask for clarification. The good thing was that I responded to the consultant order immediately without any delay. Fortunately, nothing negative happened to the patient. The bad thing about the situation is that I did not ask the recovery nurse if the initial bag was to have been the last dose. I checked all the orders carefully before the recover nurse left. I feel that both the nurses and the doctors made mistakes. The assistant consultant did not cancel the order from the system and this means that the medication is to be given regularly and not as a stat dose only for one time.
Chapter III -- Gibb's Reflective Cycle
Gibb's Reflective Cycle can and should have been applied to this situation. There are six steps to the Gibb's Reflective Cycle. They occur, as noted by the title in a cycle or circle and the process is ongoing. The steps are description, feelings, evaluation, analysis, conclusion and action plan. A description would be an honest and complete description of what occurred. This is what I did above. The feelings would be what the person involved in the event was thinking or feeling. I was upset that an error was made even though it was not initially my fault. The evaluation state is what was good and bad about the experience. It was eventually good that I learned from the event but the event itself was obviously bad. The key for me was to learn from the event. The analysis component asks me what sense can be made of the situation. I analyzed what happened and why. The conclusion is what else could or should have been done relative to the situation. This was done by me when I planned...
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