You are on your hospital’s Peer Review Committee (PRC). You are reviewing Nurse A’s practice. She works on the pediatric unit. In the past, Nurse A has practiced safely without incidents. However, four months ago, Nurse A gave immunizations to five pediatric patients (3 months, 9 months, 2 years, 4 years, and 5 years of age). She used a vial of Hepatitis B vaccine that had been expired for 30 days but still was being stored in the unit refrigerator. She gave the five immunizations within a few minutes of each other, and she got the vial from the refrigerator only once (i.e., She did not take it out and replace it five times). She took responsibility for the errors when she was informed by her unit manager.
Should Nurse A be reported to the BON?
Apply the Minor Incident Rule to reach and support your decision
- Criteria. First, review your learning about minor incidents – those which are NOT reportable to the BON. List the 4 criteria that are essential in determining if an incident is not “minor.”
- Minor Incident? Apply the facts of the case to each criterion above. Record your explanation as to whether the facts support or do not support each of the criteria.
- Your Decision. Record whether, as a member of the Peer Review Committee (PRC), you would vote to report or not report Nurse A to the Board of Nursing. (Insert an X in the box that reflects your decision.)
