Question

1. David, 4 months old boy, was admitted to the Paediatric ward of the Children's hospital 3 days ago because of diarrhea and stayed in Bed 2. You were the primary nurse of David and worked in afternoon shift today. David's health condition has improved and ready to be discharged home today i.e. 10 December 2019. You have informed David's mother on phone and she replied that she could come to pick David up after office hour. After the shift handover at 2:45 pm, you conducted patient round and noticed that David was not in his cot. His identity bracelet with security alarm tag was found on his bedside locker. Mother of Lucy, the patient next to David told you that she saw a tall lady in yellow dress had left the cubicle with David and his belongings 20 minutes ago. You have done the following actions Time action Inform ward in-charge. Perform local search in ward area. Contact hospital security staff for hospital search in parallel with David and the lady's description. Inform on call MO Dr. Chan TY and David's mother that 2:48pm 2:50pm 2:55pm David cannot be found Report to police. 3:00pm At 3:10 pm, you received a call from David's mother saying that, upon her request for help, her elder sister had brought David home already without informing ward staff. David, who appeared cheerful, was brought back to ward by his aunt at 3:30 pm. On call MO Dr. Chan TY examined him with no abnormality detected, police was informed. David was discharged home with his mother at 4 pm. a) Prepare an incident report to be submitted to the nurse in-charge before the end of your duty. (9 marks) b) In view of the above incident, the ward manager is planning to initiate a change in safety culture to prevent similar incident from happening in the future. It includes staff education, guideline reinforcement and drill. However, she encounters resistances from a few ward staff because they believe it is only a single incident and David is mistakenly brought home by his relative. Discuss how the manager carries out the planned change with reference to the Kurt Lewin's force field model of change. (6 marks)

Answer 1

A) Incident report :

Date of incident - 10/12/2019

Time - 2.45 pm

Name of injured person - David

Gender - Male

Age - 4months

Type of incident - child was abandoned

Details - At 2.45pm when the nurse went for rounds she noticed that David was not there in the cot . His identity bracelet and security alarm tag was found in the bedside locker . The mother of the patient next to David told that she saw a tall lady in yellow dress had taken the child and belongings 20mins before.

At 2.48pm - the ward incharge was informed and performed the local search.

At 2.50pm - contacted hospital security staff for hospital search in parallel with David and the lady's description .

At 2.55pm - Informed on call MO Dr. Chan TY and David's mother that David cannot be found .

At 3pm - police was informed

At 3.10 pm - I got the call from David's mother saying that ,upon her request for help her elder sister had brought David home without informing ward staff .

B) Kurt Lewin Force Field Analysis :-

Driving and Restraining forces oppose each other with the current state being at the center. In this case the ward manager makes the change in safety culture and resistance from few ward staff oppose each other with keeping the main point i.e. to ensure safety of patients .