Ishikawa Case Study Nursing

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1.0 Introduction (43)
Risk management is define as the process of evaluating situations that might lead to a loss and then selecting a course of action to eliminate the risk, reduce the likelihood that the loss will occur, or reduce the impact should the loss occur (McEachen & Keogh, 2007).
2.0 Case scenario (183)
Staff nurse Mary who was working in the cubicle had dispensed and handed Mr Tan's anti-hypertension medication to a final year nursing student Alice. Meanwhile, staff nurse Mary was in a hurry to finish up her report as there will be another admission within an hour.
As student nurse Alice is about to give the medication to Mr Tan, she saw Mr Tan's neighbouring patient (Mr Abu) is about to fall while he is trying to stand up. Immediately,
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Therefore, a single cause might not trigger the event unless all causes are present in parallel, in a series or a hybrid of both. Hence, Ishikawa diagram act as a visualisation tool for categorising the potential causes of a problem to identify the causes.
Few factors that contributed to medication error. One of the reasons occur due to poor communication between staff nurse Mary and student nurse Alice. Student nurse Alice did not inform the staff nurse Mary that she could not serve medication without any supervision. Besides that, student nurse Alice also did not inform staff nurse Alice that she left Mr Tan's medication on Mr Abu's cardiac table in which causes Mr tan not to take his medication instead Mr Abu took it.
Another reason was non-compliance towards hospital protocol due to lack of knowledge and competency. Staff nurse Mary breaks the six rights of medication administration by not serving the medication directly to Mr Tan. Thus, Mr Tan did not take his medication. Furthermore, Alice placed the medication on the wrong cardiac table which causing the wrong patient (Mr Abu) to take the
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In this case, staff nurse Mary and student nurse Alice failed to ensure that Mr Tan and Mr Abu received a safe and efficient care due to placing wrong medication on patient's table. Therefore, as a future nurse, I learn to abide by the six rights of administering medication
Singapore Nurse Board Code of ethic Value statement 6 suggested that Nurses should assign tasks or delegate care based on the needs of the clients, and on the knowledge and skill of the provider. Hence, Staff nurse Mary did not delegate the appropriate task to student nurse Alice which causes medication error. In future, I learn to delegate task according to the five rights of delegation to minimise the chances of the wrong delegation.
5.0 Conclusion

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