Risk Management (Barcos, Cruz)

Yasmine Dubois is the nurse manager for the cardiac cathererization lab and
special procedures unit in a suburban hospital. The hospital as an excellent
reputation for its cardiac care program, including the used of cutting-edge
technology. The cath lab utilizes a specialized computer application that records
the case for the nursing staff, requiring little handwritten documentation at the
end of a procedure.

Last month, 56- year-old woman was brought from the ER to the cath lab at
approximately 1900 for placement of a stent in her left anterior descending
coronary artery. During the procedure, the heart wall was perforated, the patient
coded and was taken in critical condition to the OR, where she died during
surgery.

Two days following the incident, the patient’s husband requested a review of his
wife’s medical records. During his review, he pointed out to the medical records
clerk that the documentation from the cath lab stated that his wife” . . . tolerated
the procedure well and was taken in satisfactory condition to the recovery area. “
The documentation was signed, dated, and timed by Elizabeth Clark, RN. The
medical records director notified the hospital’s risk manager of the error. The risk
manager investigated the incident and determined that Elizabeth Clark’s charting
was in error.

Following her meeting with the risk manager, Yasmine met with Elizabeth to
discuss the incident. She showed Elizabeth a copy of the cath lab report. Elizabeth
asked Yasmine if she could have the chart from medical records so she could
correct her mistakes. Yasmine informed Elizabeth that she couldn’t correct her
charting at this point in time. But, she could, however, write an addendum to the
chart, with today’s date and time, to clarify the documentation. Yasmine also told
Elizabeth that the addendum would be reviewed by the risk manager and the
hospital’s attorney prior to inclusion in the chart.

To ensure compliance with the hospital’s documentation standards and to

Creative Problem Solving (Bodota, Barte)

Jeffrey was just promoted to manager of an acute care clinic, which recently
expanded its hours from 6 A. M. Until 10 P.M. Jeffrey has realized that staff
nurses are reluctant to sign up and do quality chart audits. He gathers information
about quality improvement, reviews the literature on motivation and incentives,
and discusses the issue with other nurse managers (preparation). He continues to
manage the clinic, thinking about the information he has gathered but does not
consciously make a decision or reject new ideas (incubation). When working on a
new problem, self-scheduling for the change hours, he realizes a connection
between the two problems. Many nurses complain that by the time they receive
the schedule the day shifts are filled. Jeffrey states that he will review the chart
audits and that those nurses who regularly participate in quality improvement
projects will receive a “perk.” They will be allowed, on a rotating basis, first choice
at selecting the schedule they want to work (this is the insight stage). He discusses
the plan with the staff and proposes a 2-month trial period to determine whether
the solution is effective (verification).
Budget Management (Aya-on, Colinas, Cabauatan)

Byron Marshall is nurse manager for the Surgical Services department of a private
orthopedic hospital. Byron has received notice from the vice president of Clinical
Services that next year’s budget will be due to her for review at the end of the
month. Byron has kept careful records during the previous 12 months for use in
preparing the Surgical Services department budget.
Each month, Byron has received and reviewed monthly reports of revenue and
expense for his department. He validated each month’s budget targets, carefully
noting areas that didn’t meet budget projections. For example, when April
pharmacy charges were 15 percent above budget projections, Byron noted that
surgery volume was up 30 percent over the previous year, accounting for the
increase in preanesthesia drug charges. Nursing salaries also over budget for the
year, but again, increased surgery volume had resulted in the addition of two full-
time surgery technicians to the department. When summer vacations resulted in
agency staffing in the OR. Byron saved copies of the approval from the vice
president and the Human Resources department and noted the total cost to his
department.
Byron will use the budget information for the past 12 months to project the next
fiscal year’s budget for his department. Information from the Human Resources
department provides data for cost of living and merit increases in salary, while
Materials Management has projected a 20 percent across- the- board increase in
surgical supplies and pharmaceutical charges. Byron will also request replacement
of two OR tables and three gurneys as part of the capital budget. These items had
been requested by staff during the last department meeting when Byron asked
for changes and improvements in the budget. Budget discussion is part of each
staff meeting and Byron provides copies of actual budget numbers to the staff
each month. He has found showing revenue and expense reports to staff
increases compliance with overtime expenses and supply usage.
With monthly preparation, good record keeping, and accurate analysis Byron is
confident his budget presentation will be on time and on target.
Progressive Discipline ( Casinao, Dacuma, Bornales)
Katie Connors is nurse manager of the birthing center in a metropolitan hospital. The hospital has several
different nursing programs that utilize various patient care units for clinical instruction. A student nurse,
Amber Schroeder, was assigned to work with Natalie Cole RN, for the day shift. Natalie and Amber’s patient
arrives at the birthing center for induction of labor. During the admission process, the patient confides to
Natalie and Amber that she is terrified that she might need a caesarian section. Amber tells the patient that a
young woman and her baby recently died at the hospital during an emergency C-section. The patient begins
to hyperventilate, refuses to let Natalie continue with the admission, and threatens to leave the birthing
center. Natalie is so angry at Amber for scaring the patient she grabs her by the arm and pulls her out of the
room. Natalie loudly berates Amber in the hallway to the point that Amber is crying.

Katie hears the commotion in the hallway and instructs Amber to sit in the staff lounge until her instructor
can return unit. Katie and Natalie reassure the patient, who allows Natalie to complete the admission
process. Throughout the shift, Natalie tells every staff member and physician about Amber’s “stupid
comment”. Katie speaks with the nursing instructor and Amber about the incident. She also checks back with
the patient and gently gathers facts about the incident.

Katie is concerned about Natalie’s response to the situation. While Natalie has excellent nursing skills, she
has often been abrupt or rude to other staff members. Katie has coached Natalie on her communication skills
in three other specific incident and verbally warned Natalie her lack of professional communication. After
discussing the incident with the human resources manager, Katie agrees that a written warning will be placed
in Natalie’s personal file.

At the end of the shift, Katie request that Natalie come to her office to discuss what happened with the
student nurse. Katie informs Natalie she is disappointed in how she reacted to the inappropriate comment
made by the student nurse. Specifically, physically grabbing the student and verbally attacking her in front of
patients and staff was unacceptable and violates hospital policy. Further, Natalie continued to disparage the
student to other staff and physicians, which is also unacceptable. Natalie expresses her frustration at the
thoughtlessness of Amber’s comment. Katie tells Natalie that while Amber’s comment was inappropriate.
Natalie’s response was also inappropriate. Katie reinforces to Natalie the importance of professional
communication at all times and reviews the communication points she had provided to Natalie in the past.
She also informs Natalie she will have a written warning placed in her personnel file. Natalie apologizes for
her actions and assures Katie she will work on her communication skills. Katie documents the incident and
follow-up action in Natalie’s personnel file.