April 2019

What would you do?

The following scenario demonstrates your accountabilities when you make a mistake in practice.

Pat, a newly registered RN, recently started working in a stroke rehabilitation unit. During a busy day shift, Pat accidentally gives amitriptyline to the wrong patient. Once Pat realizes her mistake, she’s horrified. She knows she did the necessary safety checks before administering the medication. On review, she realizes that the patient shares a last name with another patient on the unit, and she mixed up the patients.

Pat monitors the patient closely. There are no immediate adverse effects. Since the patient seems unharmed, Pat wonders if the health care team, or the patient and their family, need to be informed. She’s embarrassed about her mistake and doesn’t want to tell anyone. She’s unsure what to do next.

A commitment to her patient

Pat considers all the ways her mistake could affect the patient. She continues to closely monitor the patient for adverse effects.

She also thinks about her therapeutic relationship with the patient. Pat knows that trust is at the core of a therapeutic relationship, and that lying or omitting important information can irreparably damage that relationship. Pat realizes that in order to maintain the therapeutic relationship, she must be honest with the patient and include them as partners in their care.

Pat knows that she must always put patients first. She realizes that keeping her mistake secret in order to protect her professional reputation would be putting her own needs before the needs of her patient.

A commitment to creating a quality practice setting

Pat also reflects on why she made the mistake and the factors that led her to mix up the patients. If she made this mistake, it’s possible other members of the health care team might as well. Pat realizes that in order to prevent a similar error from happening again, she needs to speak up. She can advocate for her patients and provide them with the best possible care by making sure no one else makes a similar mistake.

A decision is made

Pat tells her charge nurse about the mistake. Together, they discuss ways to prevent someone else on the health care team from making a similar mistake. Pat also tells her charge nurse that she has never had to disclose a mistake to a patient before. Pat realizes this is a learning need and asks for her charge nurse’s help. Together, they discuss the best way to inform the patient.

After disclosing the error to the patient, Pat reflects on the day’s events and her role in them. She knows the error is an opportunity to learn. She thinks about her strengths, opportunities for improvement and key learning needs.

Putting patients first

When Pat disclosed her mistake to the team, she made the right choice to put her patient’s needs ahead of her own. She was also advocating for a quality practice setting and ensuring that future patients will receive safe care. By speaking up and putting her patient first, Pat was upholding the principles in the nurses’ Code of Conduct and meeting her accountabilities outlined in the Professional Standards, Revised 2002 and Medication practice standards. She was also meeting her professional duty to report any error, behaviour, conduct or system issue that affects patient safety.

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