Ethical Dilemma Regarding on Nurse Being Quiet Despite of Error Made by

Colleague
Nurse Sophia Patrice has been reading a lot about
the patient safety movement and the disclosure of errors
to patients and their families. She cannot stop thinking
about the following incident that occurred while she was
a resident.
While on call she was asked to see a woman whose
labour was being induced with oxytocin or syntocinin. The
fetal pH was becoming unacceptable and after
consultation with her attending physician she elected to
proceed with a C-Section. Once the oxytocin or syntocinin
was discontinued, the fetal pH returned to normal so
there was no urgency. She suggested an epidural be used
but the young anesthetist wanted to do an immediate
general anesthetic.
This suggestion, as well as the anesthetists
experience level concerned her, but she said nothing. The
young anesthetist did not recognize nor know how to
manage the womans extremely small mandible and they
watched both the mother and baby die.
At the inquiry she was called to testify but was not
asked, nor did she volunteer, information about this
aspect of the tragedy.
She did not speak to the anesthetist despite having
seen similar problems without consequences in the past.

Responses to this issue:

In todays complex environment, we would expect
the disclosure would have occurred on perhaps multiple
occasions. As always, comments about the performance
of an individual team member would be avoided.
It strikes me as quite difficult to address the decision
made without questioning competence, although if this
were to become a finger-pointing exercise no one would
be well-served.
The question I would have, in this case, is what
support was given to the anesthetist? This situation might
and more than likely would be a career altering event.
Support from his/her colleagues and institution would be
crucial.
The easy answer would be to tell the physician that
he should have spoken up but speaking up can be very
difficult. People nowadays are reluctant to speak up and
admit to themselves that theyre wrong. Admitting our
own errors is difficult and pointing out someone else's can
be just as hard. However, it can be easier if we recognize
that we are human and we all make errors.
The patient safety movement calls for a shift in how
we interact with each other and with our patients to
minimize errors. Medicine is experiencing a cultural shift

where it is not only acceptable but also expected that we

will help our colleagues when we see the possibility of an
error occurring. Evaluation of a critical incident looks at
all the factors involved: fatigue, culture, hierarchy,
equipment, etc. When an error occurs we are encouraged
to disclose in a compassionate and honest fashion with
our patients.

Submitted by: Esguerra, Philine Yvonne B.

BSN II-A