Reflection Questions:

Students will answer reflection questions upon completing the story. These questions are aligned with the QSEN competencies and are designed to help the student reflect on both the content of the story and the QSEN competencies addressed by the story.
*Following each question are some potential answers

1. What could Dianne have done to avoid the critical error she made?
   A: She should not have answered her phone while administering medication. It is important that nurses are not interrupted or distracted by anything while giving medications.
2. How could this team better manage interruptions during medication administration?
   A: The change nurse could take phone calls or messages for nurses when they are giving medications. Another way to avoid this is to only take the medication for one patient at a time. The nurse could have avoided this by only taking Mary’s medication with her and returning to the med room to get the next patient’s medication.
3. What protocols should be in place across the team to ensure that errors like this do not occur?
   A: One protocol could be in place that limits the number of interruptions nurses have when administering medications. At some facilities the nurse wears a special “medication” vest and does not engage in conversations with anyone until the medication has been administered.

Reflection Questions:

Students will answer reflection questions upon completing the story. These questions are aligned with the QSEN competencies and are designed to help the student reflect on both the content of the story and the QSEN competencies addressed by the story.
*Following each question are some potential answers

1. What does this story illustrate about the importance of being prepared for emergent events?
   A: It is important to be prepared for emergent events, even if they do not occur very often. This can be difficult when it is not a regular occurrence.
2. How could this team have been better prepared for this emergent event?
   A: One way would have been to clarify the correct kit the physician wanted and to charge the hair clippers. It is also a good idea to have a few sets of supplies available and not just one set.
3. What proactive strategies could be put in place in this hospital to avoid a repeat of an incident like the one in this story?
   A: One way is to ensure staff are responsible for keeping their work areas organized and stocked with supplies. This should be everyone’s responsibility and not just that of the nurse.

1. Why was Kathi’s intervention on Deloris’s behalf so critical in this case?
   A: This patient has a history of DVT and it is important to avoid this from happening again. High workload periods make it difficult to comply with standards of care.
2. What does this story illustrate about the importance of developing a culture of teamwork that includes task assistance?
   A: Health care professionals must be diligent to provide quality safe patient care no matter how busy their assignment may be. Teamwork is an important part of providing quality care for each patient.
3. How did this team successfully monitor compliance with evidence-based VTE prophylaxis policies? What could they improve?
   A: They monitored VTE prophylaxis, but it did not appear to be in a standardized way. It was by chance that Kathi assisted Deloris’s patient. This could be improved by having set standards to use when caring for every patient at risk of developing a DVT.

Reflection Questions:

Students will answer reflection questions upon completing the story. These questions are aligned with the QSEN competencies and are designed to help the student reflect on both the content of the story and the QSEN competencies addressed by the story.
*Following each question are some potential answers

1. What does this story illustrate about the importance of involving the patient’s family and caregivers in discussions and care of their loved ones?
   A: A patient centered approach, should always involve the patient and family
2. How did Jimmy’s explanation of VAP
   A: Jimmy gave the explanation of ventilator acquired pneumonia without fully understanding that Gladys was not understanding. A patient (mother) centric approach would have provided a detailed explanation and a step by step approach to allow the Gladys to feel a part of the care team.
3. How did Penelope’s reaction to Gladys’ mistake create a positive patient care experience instead of a negative one?
   A: She was not only a patient advocate, elevating Glady’s ability to provide excellent oral care, but a therapeutic educator.
   A: Penelope’s non verbal communication was highly effective in not inducing fear or frustration in Gladys, but encouraging a learning and therapeutic interaction.

Reflection Questions:

Students will answer reflection questions upon completing the story. These questions are aligned with the QSEN competencies and are designed to help the student reflect on both the content of the story and the QSEN competencies addressed by the story.
*Following each question are some potential answers

1. What does this story illustrate about the importance of always focusing on patient safety and care?
   A: Care based on evidence based practice ensures patient safety. It is based on facts and research and not a healthcare professionals opinion or convenience. The nurse was focused on the safety and care of the mother and unborn baby.
2. How did Dr. Walters’ lack of teamwork impact Pamela’s experience at the hospital?
   A: Pamela heard what was happening in the delivery room, but could not fully understand what was happening with her baby.
   A: Pamela had to make assumptions about the health of the unborn born baby because the doctor did not explain anything to the patient.
3. What elements of a perinatal bundle were in place in this story? What elements were absent or poorly executed?
   A: The areas poorly executed in this story include how team members that did not communicate effectively with each other or the patient about their actions and patient input was sidelined. When patients lack sufficient information to make informed choices about their care then safety can be compromised.

Students will answer reflection questions upon completing the story. These questions are aligned with the QSEN competencies and are designed to help the student reflect on both the content of the story and the QSEN competencies addressed by the story.
*Following each question are some potential answers

1. What information and communication gaps occurred among the medical staff in this story?
   A: There were several issues that occurred in this story. Angela did not have the medical records from the previous infusion center and she did not call the doctor to get an order for an antiemetic, even though the patient asked for it. This situation may have been avoided if Angela would have looked at the previous chemo administration record and called the doctor for an antiemetic order.
2. What steps could this unit have taken to ensure that team members had access to all necessary information about patients when they transfer into the unit, and that they know who to talk to when information is missing?
   A: One way this can be done is by having all medical records sent to the office prior to the patient being seen. Another way would be to hold off on the medication administration until the medical records are received. The patient should have been the focus of the scenario and not the nurse and doctor blaming other people for the lack of information.
3. What does this story illustrate about the importance of actively soliciting and validating information from patients about their prior medications and care?
   A: There was a great deal of unspoken communication during this scenario due to the fact that nurse did not have all of the information. This situation may have been avoided if there were standards in place prior to chemo administration.