The nurse committed an aseptic technique error that caused injury to a newborn's IV site. When the issue was discovered, she initially denied responsibility but later admitted fault. All staff involved had a meeting to discuss the case. The baby required extended hospitalization with all expenses paid by the hospital. It was decided that the pediatrician and unit heads would disclose what happened to the parents, the hospital would cover medical costs, and a supervisor would thoroughly explain a letter asking the parents not to pursue legal action.

1. Maricor Parrenas- Agsam
MSN 1
PERCEPTION
A nurse from nursery committed an aseptic technique error causing injury to a newborn baby’s
metacarpal (right hand). At the start of her shift she didn’t check the IV site of the newborn. She was on
3-11pm shift and at 6pm the pediatrician made his rounds and found out that the IV site was very
swollen, the pediatrician informed the nurse thus she then inspected the site, stopped the clamp and
removed the IV line, placed pressure on the site using the cloth that was wrapped on the arm. The aide
who was with her shift saw what she did and immediately gave her the cottonballs using the forceps.
The following day at around 2pm the aide on duty who was feeding the baby removed the plaster was
horrified and called me, we saw hematoma (shaped like a 25 cent coin) and pus in between. In my 15
years of service I haven’t seen an IV site with pus. For me the pus was the effect of the unsterile way of
discontinuing the IV line. The case was then investigated using the incident reports of the staff involved.
During my initial investigation the aide who was with her told me the whole story but when I asked the
nurse she denied at first then eventually accepted her fault thru phone. All the staff involved had a
conference with the chief nurse ( Chief Operations officer), a supervisor and the clinical unit supervisor
(headnurse), she then bluntly denied the accusation which caused the others to become furious on her.
To make the long story short. The baby stayed long at the hospital occupying the MAB room and all
expenses paid for by the hospital.
The PERCEIVER = all the staff involved including me. ( attempts to interpret what we heard from her and
the real story from the aide, our interpretation is heavily influenced by our personal characteristics)
The TARGET = the nurse. She is friendly, helpful and laughs a lot. Good interpersonal relationship with all
staff. But does shortcuts on her work most of the time (we can do shortcuts at times but NEVER our
sterile technique esp. in the nursery). Her classmate and close friend and now a colleague attested that
she denies mistakes/ errors a lot of times.
The SITUATION = the unsterile technique that she did and the denial of her act.
The perception of all the staff on her would have been GOOD if she only accepted her mistake.
Attribution Theory:
The behavior of the nurse was internally caused because she was under control of her behavior. She was
consistent in doing shortcuts and denying her faults or mistakes as claimed by our colleague. High
internal behavior and low external behavior. For me at first without hearing from her friend, I
considered her behavior to be externally caused because she was forced by the situation by displaying
distinctiveness ( she displays different behaviors in different situations).

2. Rational Decision-Making
1. Define the problem.
Newborn had infected IV site due to unsterile technique used by nurse upon discontinuing IV.
-Who would disclose situation to the parents.
- Who would shoulder the expenses of the treatment and hospitalization?
- How to prevent lawsuit.
2. Identify the decision criteria
-The pediatrician and the assigned staffs ( CUS, Supervisor and chief operations officer) will
disclose the problem to the parents after their conference with the involved staff is done and
after their thorough investigation and conference are done.
- The involved staff and the hospital will pay for the treatment and hospitalization.
- Talk to the parents thoroughly and explain the case in a regretful manner
3. Allocate weights to the criteria
- Are the staff assigned capable of explaining the situation to the parents without being
bias to hospital?
- is the nurse financially able to assist in paying the hospital bill?
-Expect lawsuit.
4. Develop the alternatives
-Pediatrician and staff assigned to disclose situation to parents.
- In the states, lawyers and higher staff of the hospital discloses situation to the parents.
-The staff involved with pediatrician to disclose situation to parents.
- A waiver/ letter of agreement not to sue the hospital should be signed by the parents.
5. Evaluate
- The involved staff must not be the one to disclose the case to the parents because it can cause
more trouble.
- Pediatrician and Staff assigned (heads) will disclose problem to parents.
- The involved staff and hospital will pay for the expenses.
- Somebody (head) should explain the letter thoroughly to the parents and let them understand
our side.
6. Select the best alternative
- Pediatrician and Heads will disclose problem to the parents .
- The hospital will pay for the hospital expenses.
- A supervisor capable of explaining the waiver/ letter of agreement was chosen to face
the parents.