NURS 501 Week 2 Reflection Assignment on an Error and a Teamwork Breakdown Example

The Button Was Not Only the Patient's: A Reflection on Patient-Controlled Analgesia by Proxy and a Handoff That Left Out the Family

Reflection on an error is useful only when it changes what a nurse does next. This paper describes an event from my practice on a surgical unit in which a family member operated a patient's opioid pump, and the six stages Gibbs (1988) proposed for reflecting on experience give the paper its order as I examine my role, the team's communication and the systems that allowed the error.

Description

A patient in their seventies had a total hip replacement and returned to our unit with an intravenous patient-controlled analgesia pump delivering hydromorphone. I received the patient at 1900 in a handoff that covered vital signs, the surgical dressing, the pain scores and the pump settings. The handoff did not mention that the patient's daughter planned to stay overnight or that the daughter had asked the day nurse whether it was all right to press the button while the patient slept. Around 0200 the patient barely responded to my voice or a sternal rub, breathing only 7 times a minute, and the pulse oximeter read 86% despite two liters of oxygen. I stopped the pump, called a rapid response and gave naloxone under our protocol, and the patient recovered within minutes. The pump history showed many more doses in the previous three hours than earlier in the evening. The daughter explained that the button had been pressed every time the patient stirred, so the patient would not wake up in pain.

Feelings

My first feeling was fear, then relief, and then a sense of failure that lasted for days. I also felt anger at the handoff, which I am not proud of, because it kept me from looking at my own part. I had seen the daughter at the bedside at 1900 and assumed someone had already explained the pump. The assumption that someone else had taught the family was the same assumption every nurse in the chain had made.

Evaluation

Some things went well. I recognized the deterioration quickly, the rapid response team arrived within minutes, and the patient was not harmed in the long term. What went badly was everything before 0200. Nobody had taught the daughter that only the patient may press the button, the pump's safety depends on the patient falling asleep before an overdose, and our handoff tool had no place to record who was at the bedside or what the family had asked.

Analysis

Three gaps lined up. The first was education. Patient-controlled analgesia is safe because a sedated patient stops pressing the button; a family member who presses it removes that safeguard. The day nurse heard the daughter's question but was called to another room and did not return to it, and I never asked. The second gap was the handoff. Choi et al. (2024) reviewed 18 studies of educational programs for nursing handovers and found that the effective programs used active practice, such as demonstration, role-play and feedback, and taught nurses how to select the information that matters for safety. Our handoff covered the information a standard form prompts for and nothing more. A question from a family member about a high-alert pump is exactly the kind of detail a trained handoff would carry.

The third gap was risk assessment. Our unit screens surgical patients for risk of opioid-induced respiratory depression, and this patient had been scored as low risk. Hutcheson et al. (2025) compared three validated opioid risk tools in a matched case-control study of 126 surgical patients and found that none of them was associated with escalation of care for respiratory failure. That finding does not mean screening is useless, but it warns against treating a low score as permission to relax monitoring. Our patient had no continuous monitoring beyond intermittent vital signs, so the slowing breathing went unseen until my next rounding. Looking back at the vital signs, the respiratory rate had drifted from 16 to 12 between the 2200 and 0000 checks, a change that sat inside the normal range and that nobody, including me, treated as a signal. With an opioid pump running and a visitor at the bedside, a downward trend should have prompted a sedation score and a closer look at the pump history. Trends, not single values, are often the first sign of opioid-induced respiratory depression, and our documentation system displayed each value alone.

The ethical issue is real as well. The daughter acted out of love and a wish to relieve suffering, which reflects beneficence, but without understanding how the pump protects a sleeping patient, that kindness produced the harm it was meant to prevent. The nurses' duty of nonmaleficence includes teaching families enough that their kindness does not become dangerous. Respect for the patient's autonomy also matters, since a pump designed for patient control was being controlled by someone else.

Conclusion

I could have prevented this event by asking one question at 1900: "Has anyone talked with your family about the pump?" The handoff and the risk screen contributed, but so did my assumption. The event showed me that safety with high-alert medications depends on information that forms do not prompt for, and that family members at the bedside are part of the care team whether or not we include them.

Action Plan

I made three changes. First, I now teach every family member present at the start of my shift about patient-controlled analgesia, using teach-back, and document it. Second, I brought the event to our unit practice council, which added a line to the handoff form for visitors present overnight and any family questions about high-alert medications. Third, I supported a proposal for continuous pulse oximetry and capnography for all patients on opioid pumps during the first postoperative night regardless of risk score, which the council is reviewing. As a future advanced practice nurse, I also intend to use this event when I teach new graduates, because the lesson is less about the pump than about assumptions.

References

Choi, J. Y., Byun, M., & Kim, E. J. (2024). Educational interventions for improving nursing shift handovers: A systematic review. Nurse Education in Practice, 74, Article 103846. https://doi.org/10.1016/j.nepr.2023.103846

Gibbs, G. (1988). Learning by doing: A guide to teaching and learning methods. Further Education Unit, Oxford Polytechnic.

Hutcheson, S., Pehrson, A., Gassert, R. B., Guffey, E., Shanahan, P. C., Sisk, L., Patton, S., & Solla, C. A. (2025). Risk stratification for postoperative opioid induced respiratory depression: A retrospective case-control analysis of existing validated tools. Journal of Pain Research, 18, 2233-2240. https://doi.org/10.2147/JPR.S495181