A staff nurse was assigned to care for five patients on a busy cardiac unit for weekend dayshift. Normally, each nurse is assigned four patients but one nurse called out sick and the nursing supervisor was unable to find a replacement. Midway through the Sunday morning shift while the nurse is administering medications to a patient, another of the nurse’s five patients falls trying to get out of bed without assistance and sustains a wrist injury. The following Monday, the nurse manager, the weekend charge nurse, and the staff nurse meet to discuss the patient’s fall. The nurse is worried about being blamed for the fall and being disciplined.

1.

What cues might the nurse identify and consider in this situation?

2.

What hypothesis will the nurse consider based on the available information?

3.

What processes might the group apply in working to identify contributing factors for the patient’s injury?

4.

How can the three nurses work together to prevent future patient falls?