March 27, 2012

TO:

MR. JOHN DANIEL OCHOA, RN

ICU-Head Nurse, SLHMC

Dear Sir/Maam:
This report will outline the incident which occurred last Saturday, March 24, 2012 in
my morning shift as the nurse-in-charge while Ms. Raiza Misolas as the bedside
nurse of patient Capuz Sr. The incident occurred as a medication error in the form
of giving an oral medication at the wrong time. Prior to his confinement, the patient
is known to be taking his maintenance medications (written in a prescription paper
handed over to me by the patients relative), including the one that was mistakenly
given at an earlier time when it was supposedly should be given at night. When he
was admitted in the ICU, these maintenance drugs were only resumed as ordered
by the attending physician and was administered after the patients condition
became stable.
Before 12 noon, when the order was received, indicating to resume his maintenance
medications as prescribed to patient Capuz Sr., I was carrying out the order of his
attending doctor on the chart then afterwards I was also reading new orders
received for patient Uy (another ICU patient whom I also served as the charge
nurse) after the same attending physician made her rounds to the patient. Knowing
that there were too many orders received for both patients, I decided to prioritize
patient Uy in carrying out the orders, since this patient needs more prompt
attention and her condition is less stable than patient Capuz Sr. when the bedside
nurse, Ms. Misolas asked me a question similar to this statement: Ibibigay ko na ba
lahat ng meds niya (pointing to patient Capuz Sr.)? At this point, I nodded as my
approval and checked the medication box (given by patient Capuz Sr.s relative)
placed at the station and let her also see the prescription paper to check on it.
On the other hand, a couple of minutes later, since patient Uy has to undergo a
blood extraction (ABG) as ordered, and that there was no available RT that day as
per allied staff member, I called the attention of the resident doctor who came in
the ICU and the allied staff member to assist him in blood extraction. While waiting
for the allied staff member to arrive, I assisted the resident doctor to prepare for the
patient (Uy). Few minutes later, the allied personnel came to assist the resident
doctor on blood extraction. At this point, I was able to carry out pending orders for
patient Capuz Sr. and was able to update his chart. At around 12 noon, when I was
updating patient Uys chart and patient Capuz Sr.s medication sheet for his
resumed drugs, Ms. Misolas asked me again the same question as mentioned
above. I replied Opo, as my response and she was able to administer these drugs
to the patient (Capuz Sr.), which has come to my attention that she already knew
giving the right drugs as prescribed.

Later that moment, the resident doctor failed to extract blood from patient Uy. He
then suggested that another resident doctor to perform the procedure, so I called
the attention of the resident doctor he was referring to and when the procedure was
performed successfully and that the result was obtained, the former ROD returned
in the ICU and was writing orders for patient Uy on the chart when Ms. Misolas
called my attention and said in this similar statement, Sigurado ka bang lahat ng
meds niya, ibibigay? Then it has come to my attention that the word lahat she
was referring to, were the drugs including the one that was supposedly to be given
at night. At this point, I realized that Ms. Misolas had mistakenly given the drug. As
the nurse-in-charge, it came upon me that I was involved in the incident as I had let
her give a drug at the wrong time. This led to the submission of this report.
After the time of this incident, I remained quiet for awhile and resumed my duties
as a charge nurse to both patients. After the shift, I felt ashamed for giving a wrong
decision which has caused miscommunication between my senior nurse and I. I
suddenly became aware that every response I give to the bedside nurse is very
important especially when it comes to rendering care including giving the drug to
the patient at the right time. Though a bedside nurse, Ms. Misolas was also able to
help me through in carrying out orders of both patients when I was assisting the
attending physician for the incoming orders and other important data which I also
relayed to the doctor.
As for the patient, later that afternoon, patient Capuz Sr. was transferred to a
regular room as ordered, and I was the one who endorsed the patient to the
receiving staff nurse of in-patient department. I therefore emphasized that the
mistakenly administered drug was already given at an earlier time and its next dose
must be given the next day at night-time.
This incident made me realize that good communication between two nurses is very
important. However the situation appears to be demanding, a nurse must know how
to deal with it and manage the situation with proper attention when it comes to
patients safety by giving the right drug at the right time. I sincerely apologize for
this incident to happen and this had served me a lesson as part of my experience as
a staff nurse of the institution. I assure you that this incident will not happen again. I
am hoping for your consideration with regards to this issue. Thank you and God
bless.
Sincerely yours,
Alexis Roy C. Encarnacion, RN
ICU-Staff Nurse