September 2, 2013

Rodolfo C. Borromeo, RN, Ed.D Director, Nursing Service Division San Juan de Dios Educational Foundation, Inc. (Hospital)

Dear Mr. Borromeo: Greetings in the name of our Lord! This is to give an account of an incident which took place during our 6am-2pm work shift on August 19, 2013, Monday. The setting was Sto. Nio Unit of SJDEFI Hospital. I was working as Nurse-in-charge (NIC) for the 15 patients still admitted that day. With me were Ms. Ela Sumalbag,RN, the Nurse 2 tasked with 5 patients; and Mr. John Reyman Dabuet,RN, the Nurse 2 also with 5 patients. I was also in-charge of 5 patients. At about 10am that morning, Dr. Bacsain-Andres made rounds for her patients. One of her patients at Room 462, (Fajardo, XX) received orders for discharge from her. I was in-charge of the said patient at Room 462, and as per the nurses responsibilities, I carried out the recent order. I checked items charged to patient Fajardo which may be returned, and after clearing them, I queued the patient for discharge through the IHCS. Last Friday, August 29, Ms. Lilibeth Ferma, our unit manager informed me that patient Fajardo at Room 462 was discharged that day without clearance from the Central Supply Unit. More from this concern, the patient utilized Oxygen with all its accompaniments, e.g. Oxygen Tank, Tank Holder, Oxygen Regulator, and No Smoking Signage during his stay in the hospital. The said items were not charged to the patients account because he was not cleared before discharge In my assessment, this incident occurred because the nurse in-charge of the said patient was not able to check the availability of Oxygen paraphernalia at the bedside before completing the discharge queue. My first recommendation, therefore, is for nurses, whichever method of care their unit may be using, to be extra careful in the process of discharge queue. Availability of Oxygen or other borrowed hospital properties and other returnable pharmacy items and medical supplies should be doublechecked before queuing through the IHCS. I also recommend contacting the Central Supply Unit for clearance in Oxygen or other items prior to queuing. Another preventive measure I can recommend is an availability of a pending request for Oxygen use through the IHCS, much like a pending request done for ancillary medical services (laboratory, radiology, pulmonary services etc.), or a pending request done at the Operating-Delivery Unit. This

way, the use of oxygen will be a pending request subject for account charging prior to the patients discharge. May these narrations bring light to what transpired that day. I aslo hope the recommendations will be helpful to prevent this incident from re-occurring. Thank you.

Respectfully yours, Anna Pauline Baltazar, RN Staff Nurse, Sto. Nio Unit

Noted by:

Lilibeth Ferma, RN Unit Manager Sto. Nio Unit

Juliet D. Borja, RN, MAN Section Manager Mother and Child Care Section