Case Study VIII
Mbinglo Peter
Lakeview College of Nursing
N309, Nursing of the Gerontological Client
 July, 08, 2011

Case Study VI		
1. 	She needs to file an incident report according to her healthcare agency policy. In this case it is a Medication Occurrence Information Report/PI (Taylor et al, 2010). She also needs to keep an eye on the patient to note any problems. 
2.	 Several things could and should have been done to prevent the error; Patients should have means of identification like names on their head bed or on their drawer. A new worker should be assigned another nurse to work with till she knows the patients or how the healthcare facility functions (Arnold & Boggs, 2011). Jane should have performed the 6 rights of medication which are; right medication, right dose, right route, right time, right reason, and right person, but she did not. She failed to ask the patient to identify herself before giving her medication (Taylor et al, 2010). Jane should have gotten another worker to confirm the patient’s identity before giving medication. But most of all, she failed to follow the policy of her healthcare agency and law governing administration of medication - which are the three checks (Taylor et al, 2010). 
3.	 Jane is mostly responsible for her error because she failed to identify her patient before given medications. She did not follow law governing medication administration, the three checks. Though the CNA identified the wrong patient, it was left on Jane, who was administering the medication to make sure she gave the right medication to the right patient. According to Taylor et al, (2010) Nurses are considered the last persons to catch or correct a mistake, thus they take the blame for most mistakes. The facility equally failed to make available some sort of identification of her clients. This should also serve as a teaching for all healthcare facility, like the one Jane is working with, to make sure they have visible ways that clients can be identified. The clinical instructor had no part in Jane’s mistake; she had passed on the knowledge and training to Jane but Jane failed in her execution. She did follow medication administration precaution.
4.	 The ethical implication in this situation is how to admit honestly that an error has occurred in an objective manner. Then followed by apologizing for it which means accepting the guilt. With guilt, the next thing is coming out with ways of correcting the mistake while bringing to the table ways to prevent the mistake from happening again (Mauk, 2009). Legal implications here are malpractice litigation in which liability has to be proven if harm is done or sentinel which involves serious harm like death or lost of a limb (Taylor et al, 2010). This can be very costly to either Jane or the long term care facility. At the end, Jane could go to jail if death ensured from the mistake. She would lose her license and may never have to practice nursing, a thing she has invested her time into. 
5. 	If a mistake occurred in the facility I was working in say a hospital, I would make sure I follow the policy on what to do. However I would immediately notify head nurse, file an incident report while keeping an eye on the patient for any signs of toxicity or side effects. I will admit my fault and explain how the mistake happened. Most of all, I will propose ways that the mistakes can be prevented from repeating.

Reference
Arnold, E. C. & Boggs, K. U. (2011). Interpersonal relationships: Professional communication 	skills for nurses. St. Louis, MO: Elsevier Saunders.
Mauk, K. L. (2009). Gerontological nursing: Competencies for care (2nd ed.). Boston, MA: 	Jones & Bartlett.
Taylor, C., Lillis, C., LeMone, P., & Lynn, P. (2010). Foundation of nursing: The art and 	science of nursing care. Philadelphia: PA. Lippincott Williams & Wilkins.