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 2:48pm 2:50pm 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 David cannot be found Report to police. 2:55pm 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)

PS,

For part a, please include:

who to report, who to filter, who receive the information, when, where, how, the nature of the incident, what kind of immediate management intervention

For part b, please briefly explain the Kurt Lewin's force field model of change and how to apply it into this case.

please tell me what kind of information you may need to know.

Answer 1

a)I was the primary nurse for David ,a four months old boy who admitted to the pediatric ward because of diarrhea three days ago.Today was his discharge and it was dramatic.I called his mother and she replied that she could come to pick David up after office hour.After my shift handover at 2.45 pm I conducted patient round and get shocked.I couldn't fond him.His bracelet with security alarm tag was found on his beside locker.The patient next to him told me that she saw a tall lady with yellow dress had left the cubicle with David and his belongings 20 minutes ago.

I couldn't find a way what to do.I informed the ward manager and performed a local search in ward area. But they couldn't find him.Then I contact hospital security staff for hospital search by giving the description of the boy and the lady.But no result. Suddenly I inform MO Dr.Chan TY and informed the police..At 3.10 pm I 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.Dr.Chan TY examined him with no abnormality detected.Police was informed.

David was discharged home with his mother at 4 pm.Actually I get so scared today when he disappeared.Anyway we should take more care and safety measures for our patients.

b)Tips for Ensuring Patient Safety in Health Care Settings

• Tip 1: Establish a Safety and Health Management System. ...
• Tip 2: Build a Rapid Response System. ...
• Tip 3: Make Sure That Employees Know and Understand Safety Policies. ...
• Tip 4: Develop a Safety Compliance Plan. ...
• Tip 5: Practice Patient-Centered Care

Lewin's Force Field Model is an important contribution to the theory of change management - the part of strategic management that tries to ensure that a business responds to the environment in which it operates.

Lewin's force field analysis is used to distinguish which factors within a situation or organisation drive a person towards or away from a desired state, and which oppose the driving forces. These can be analysed in order to inform decisions that will make change more acceptable

Lewin's Force Field Model Forces for change Forces resisting change Driving forces Restraining forces tutor2u