The nurse is completing an occurrence report for a client in the inten

QUESTION

The nurse is completing an occurrence report for a client in the intensive care area. The client’s medications were accidentally switched with another client necessitating extending mechanical ventilation.

Prior to the occurrence the client’s hemodynamic parameters were stable, however they have been tenuous for the last 16 hours. What collected data should the nurse identify as nursing work environment variables that contributed to this occurrence? (Select all that apply.)
1. The nurse was interrupted twice while preparing the client’s medications.
2. The nurse was preparing information to share with the family prior to visiting hours.
3. The nurse did not secure the prepared medications prior to vacating the medication room.
4. The nurse worked until midnight the previous day and returned to work a twelve-hour shift.
5. The nurse was called to the telephone to take verbal orders on another client while preparing the client’s medications.

ANSWER:

Correct Answer: 1, 3, 4, 5

The IOM described the typical work environment of nurses as characterized by numerous serious threats to patient safety. Demands on nurses’ time (such as extensive documentation), frequent interruptions, and long work hours are examples of threats to safety in the work environment of nurses. For this situation, several things contributed to the occurrence: 1. the nurse was interrupted while preparing the medications; 2. the nurse did not secure the medications prior to vacating the medication room; 3. the nurse worked late the previous day returning for a long shift; and 4. the nurse was interrupted to take telephone orders while preparing the client’s medications. Preparing information to share with family most likely did not contribute to the occurrence.