Quality Improvement
Unfolding Case Study: Part 1
Brian is a new nurse and has been working on the medical unit for the last 2 months. Last month, a client died
because of a nosocomial infection. The hospital administration and educators have been speaking to staff about
reducing nosocomial infection rates and the importance of hand hygiene in that endeavor. Brian notices that Dr.
Wells enters the client's room without using hand sanitizer or washing her hands, assesses the client, and then
goes to the next client. Brian is aware that this is poor hygiene and against hospital policy. Brian is concerned for
the client's safety and the safety of other client Brian wonders how best to address the problem.
Brian is worried that because he is new that he may not be the best person to address the issue. He feels
certain that since this is a big problem, others must be watching who will speak to the doctor, so he chooses to
say nothing.
• What are possible actions that Brian could have taken instead of silence?
• What are the possible outcomes of each action?
• If Brian's client develops an infection as a result of poor hand washing practices, will Brian be held
responsible since he was aware of the problem and did nothing?
• What are Brian's ethical and legal responsibilities as a nurse?