Look at this case study scenario below.
“Nurse Karen is caring for a newly admitted 67-year-old male patient with infectious endocarditis due to a bacterial infection of his prosthetic heart valve. After blood cultures come back positive for staphylococcus aureus, IV Vancomycin is ordered. He tells Nurse Karen and the doctor that the last time he got this medication, he experienced hives and hot, itchy skin but he was not allergic to it. The doctor ordered the medication to be infused slowly as to avoid Red Man Syndrome (500 mg IV bag at a rate of two hours as opposed to the standard one hour). Karen sets the IV pump incorrectly, and the infusion is given within a 30-minute period. She calls the doctor and immediately gives 50 mg diphenhydramine and ranitidine 50 mg via IV with orders. The patient experienced mild flushing, but the episode resolved within 20 minutes. Karen is a well-seasoned nurse with over 20 years of experience and no prior history of incidents. She took immediate responsibility for this error when meeting with the unit manager. Karen will now need another RN to witness and sign when she administers IV medication for the next 60 days. Karen agrees to this plan.”
Using the Texas BON Rule 217.16, review (a) a Minor Incident vs. (h) a reportable incident. This information can be found at
https://www.bon.texas.gov/rr_current/217-16.asp.html.
Based on your assessment of the criteria, was this a Minor Incident or reportable event? Why or Why not?
Minor or Reportable?
Why? Or Why not? Include examples from the Rule.
Part 2: Applying Rule 217.19 Incident-Based Peer Review
First, review your learning about incident-based peer review. The purpose of an IBPR is to determine whether a nurse should be reported to the Texas Board of Nursing (BON) for professional misconduct or licensure violations based on one or more such events.
Please use the link provided at https://www.bon.texas.gov/rr_current/217-19.asp.html
to review. Apply the information to this case study-
“Nurse Sam is charting at the nurse’s station where there are co-workers, physicians and a unit secretary gathered. Sam and the nurse manager have not been seeing eye to eye lately (verbal altercations both in the halls and in the cafeteria recently). The nurse manager approaches Sam and loudly states, “I am glad you are here. Just to let you know, the Incident Based Peer Review Committee is meeting tomorrow, and we are investigating your recent questionable behavior. I know you have made many recent medication errors and safety violations noted by the Patient Safety Committee. I also heard you are dating that patient who was in Room 256B last month. I thought you would want to know this was happening, you could be in big trouble and probably fired. I don’t have anything official to give you, but you better find a lawyer, although I doubt you can with this short notice.”
How did this nurse manager violate the IBPR? Refer to the Rule listed below and discuss in the text box.
Rule 217.19 a (2) Bad Faith- knowingly or recklessly acting without the supported of reasonable or legal basis, misrepresenting the facts surrounding the facts under review, acting out of malice or personal animosity towards the nurse, acting from a conflict of interest, or knowingly or recklessly denying due process. How did this nurse manager violate the IBPR based on this rule?
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