Providing healthcare to patients is a complex and uncertain environment in which errors and disasters can occur despite the best intentions. When a caregiver witnesses and then suffers the negative consequences of such an event, the resulting trauma is known as “the second victim syndrome.”

You are the administrator of General Hills Hospital, a large and well-known teaching hospital. Because the facility has a cutting-edge Neonatal Intensive Care Unit (NICU), the most critically ill infants are frequently scheduled to be delivered or immediately transferred to General Hills. The registered nurses who work in the NICU are exceptional. Nurse Mary is no different.

Nurse Mary has twenty-two years of nursing experience, the vast majority of which she has spent at General Hills. She is a model employee, and the care she provides is exceptional.

You were informed this morning that one of the babies with a severe heart condition died in the NICU. You are heartbroken to learn that this infant was the victim of a serious medical error four days prior, when Nurse Mary unintentionally overdosed the fragile infant with ten times too much medication. Almost immediately, Nurse Mary realized her error, admitted it, and reported it to the hospital’s electronic reporting system. The infant was so frail that proving that the medication error alone caused the infant’s death will be difficult; however, it is undeniable that the error endangered the infant and contributed to his decline.

Since the day of the incident, Nurse Mary has been devastated. She is miserable, unable to eat or sleep, and appears to be sinking into a deep depression. Furthermore, while she feels bad even bringing it up given the circumstances, Mary is very concerned about her livelihood, specifically her license to practice and continued employment with General Hills. The case has been referred to the state nursing commission, where Nurse Mary’s case is still pending decision, but the commission is expected to place Nurse Mary on probation.

You and the other administrative staff will meet tomorrow to decide what will happen to Nurse Mary. General Hills does not have a policy dictating what happens to an employee who makes a medication error because it is a mistake with a wide range of consequences.

The mission statement of General Hills is to provide excellent medical education and patient services while maintaining a responsibility and commitment to quality, compassionate care and collaborative service.

a.Did Nurse Mary’s actions violate or comply with the Nursing Code of Ethics directives?

b.Who are the key players?

c.How would you handle the situation as a healthcare administrator, keeping in mind:

i. the mission statement of General Hills; and

ii. The professional codes of ethics to which you are bound as a healthcare administrator and a healthcare provider