Question

“A 12-day old newborn infant was hospitalized in the neonatal intensive care unit (NICU) because of multiple seizures. He was the first child of the family. The mother’s and family history was negative for seizures or any other disease. Seizures were controlled by medications, and diagnostic assessments including electroencephalography (EEG) were ordered. As the infant was stable and had tolerated breast feeding, it was planned to transfer him to the level II NICU, but it was postponed due to lack of available beds.

On the evening shift of the third day of admission, his nurse heard a sudden noise and noticed that the incubator door was open and the baby was on the floor. The in-charge nurse immediately announced the incident to the on-call physician. The newborn was examined thoroughly and no physical injuries were found. Moreover, the incident was reported to the chief physician of the department and the record of this incident was immediately sent to the hospital officials. Later, all other incubators were inspected to make sure they were secure enough.

When the staff informed the newborn’s father of the falling, he accused the mother of neglecting the child, although she had said that she was resting at the time of the incident.”

Discussion Questions:

1. What risk factors contributed to this incident?
2. How could this incident have been prevented?
3. What is the responsibility of the staff in dealing with this incident?
4. What are the ethical issues of patient safety in this case?

Answer 1

●The risk factor which could have contributed to the incident are

• Newborn ,who lacks the knowledge of external environment
• The status or the condition of the incubator where the newborn was placed
• Inability to shift the newborn due to shortage of bed in NICU2
• Lack of supervision or staffs

●the incident could have been prevented by

• Regular and daily monitoring of the equipment for its safety
• Continuous supervision
• Mother or an attender next to the infant

●The responsibility of the staff in dealing with the incident are

• Ensuring the baby is safe
• Monitoring for any injuries and providing intervention
• Documentation and filling in incident report

●The ethical issues in patient safety in this case is the negligence of the staff to handle a tender infant and pose a threat to life because of fall and infancy.The ethics of beneficence is not followed here which led to the incident.