HISTORICAL CASE STUDY

HISTORICAL CASE STUDY

Read HISTORICAL CASE STUDY #1: An Ounce of Prevention and submit APA Paper, write a paper addressing the following:

a.      What actions or inactions by the nurse significant to the propagation of infection?

b.      In your opinion, was the lack of adherence to prevention measures due to lack of knowledge or just carelessness?

Paper must be at least 1 page, excluding title page and reference page. (at least 1 reference no more than 5 years old), make sure to reference the article.

 

HISTORICAL CASE STUDY #1: An Ounce of Prevention

PRACTICE BREAKDOWN AND PREVENTION

BACKGROUND

An outpatient oncology clinic was located in a small town with a population of approximately 20,000. The clinic had been open for approximately 5 years. Dr. Dave Brown owned the clinic, and the local hospital had provided financial assistance to start the clinic.

Ms. Danielle Davis, RN, had been employed by Dr. Brown prior to the opening of the clinic. The state board of nursing received a complaint that Nurse Davis was engaging in unsafe practices.

THE NURSE’S STORY

Nurse Davis had been licensed as a registered nurse for 20 years during which time she had worked primarily in the hospital setting on the medical-surgical, coronary care, and intensive care units and in the emergency department. She accepted an offer from Dr. Brown to work as a nurse in the oncology clinic.

Nurse Davis informed Dr. Brown that she had no experience in oncology nursing. Dr. Brown assured her that he would provide her with training. He did train Nurse Davis in oncology treatment practices before she began working with patients. Her duties included administering chemotherapy, preparing medications and chemotherapy agents, accessing ports, drawing blood from ports, flushing ports, administering medications through the ports, and following proper infection control practices and procedures. Dr. Brown said that he had observed her frequently during her employment at the clinic.

The clinic had applied to participate in oncology clinical trials. A registered nurse consultant, Ms. Connie Cousins, came to the clinic to conduct an on-site inspection and evaluation. Consultant Cousins observed many substandard practices while at the clinic. She shared her report with Nurse Davis and with Dr. Brown. Dr. Brown asked that Consultant Nurse Cousins refrain from providing a copy of the report to the local hospital, but Consultant Nurse Cousins ignored this request and provided a copy of the report to the hospital.

Some of the observed substandard practices that failed to follow basic infection control requirements when providing treatment included the following:

· 1Reusing single-use disposable syringes from the same patient when accessing a bag of saline that was used for multiple patients.

· 2Injecting patient’s blood back into the patient’s port after drawing blood for lab testing.

· 3Reusing syringes to mix multiple chemotherapeutic agents.

· 4Storing admixed medications in the drug cabinet for future patient use without labeling the medications with the time and date the medication was mixed.

· 5Failing to label IV bags or syringes with the patient’s name and the contents of the bag.

· 6Maintaining food and food supplies in the same cabinet as the chemotherapy medications.

· 7Discarding chemotherapy-contaminated supplies in the regular trash container.

· 8Failing to wear gloves when providing care for patients.

ADDITIONAL INFORMATION

Ms. Joan Deming, a trained dental hygienist, was employed as a receptionist at the oncology clinic. She informed Dr. Brown on at least one occasion that she had observed Nurse Davis and the other registered nurses employed at the clinic engaging in improper infection control practices.

Ms. Brigette Ingersol was a registered nurse who worked as the infection control registered nurse at the local hospital. Several patients from the oncology clinic approached her with concerns about practices at the clinic. These practices included reusing syringes that had been used to draw blood to obtain saline from a large saline bag, then using the saline to flush patients’ ports.

Consultant Nurse Cousins’ report concluded that the nurses were unable to develop a correction plan regarding the observed unsafe practices. She indicated the part-time registered nurses were overwhelmed with information and that Nurse Davis appeared unwilling to discuss options to correct the practices.

Mr. Niles Anderson became a patient of the clinic. Mr. Anderson was positive for the hepatitis C virus (HCV). He received blood draws and chemotherapy at the clinic. Approximately 1 year after he became a patient, Mr. Walter Belin, another patient, was diagnosed with HCV. Two weeks later, Mr. Tony Caruthers, a third patient, was diagnosed with HCV. Both Mr. Belin and Mr. Carruthers were diagnosed with HCV approximately 2 months prior to Consultant Nurse Cousins’ visit to the clinic.

One month after Consultant Nurse Cousins’ visit, Nurse Ingersol met with Dr. Brown to discuss ongoing concerns expressed to her by several clinic patients regarding unsafe practices at the clinic. In the next 2 weeks, Mr. John Dickson and Mr. Dan Edison, both clinic patients, were diagnosed with HCV. Shortly after the diagnosis of Mr. Dickson and Mr. Edison, Nurse Davis resigned. In the next year, 100 clinic patients were diagnosed with HCV. Of that number, three died as a result of the HCV infection.

The board of nursing reviewed Nurse Davis’ case and recommended revocation of her registered nurse license. The license was revoked.

CASE ANALYSIS

Infection control precautions are basic to the health care profession. Safe practices are the foundation of any procedure or task. In this case, many individuals either did not maintain basic infection control procedures or were unaware that the proper precautions were not being followed. Lack of training and certification in chemotherapy medication administration also contributed to the nurses’ lack of knowledge and skill.

Nurse Davis was the full-time registered nurse at the clinic and carried responsibility for care practices of the other staff at the clinic. She did not practice basic infection control and was not aware that others were not following infection control measures.

The physician was aware of and routinely observed unsafe practices in his clinic. The nurse consultant, the registered nurse, and the infection control nurse at the hospital had made both the physician and his employee, the registered nurse, aware of the unsafe practices being conducted at the clinic.

This is a case where the use of simple infection control precautions could have prevented many individuals from becoming infected with HCV and could have prevented the death and suffering of patients in this vulnerable patient population.

 
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