The guardian of a child who has a terminally illness tells a nurse that they want to take their child home. Which of the following responses should the nurse make?

A. "The client has a new prescription for incentive spirometry.": This statement is more appropriate for the "Assessment" or "Recommendation" section, as it pertains to current treatment plans and interventions rather than the background context of the client's history.

B. "The client's partner plans to return later today.": This information is relevant to the client's social support and engagement but is not critical background information. It may be included in the "Situation" or "Recommendation" sections instead.

C. "The client has no living family members.": This statement is pertinent to the "Background" portion, as it provides important context regarding the client's social situation and support system. Understanding the client's background helps the receiving nurse assess potential psychosocial needs and planning for care.

D. "I initiated a consultation by a nutritionist.": This action relates to ongoing care and assessment of the client's nutritional needs, making it more appropriate for the "Assessment" or "Recommendation" section. It is not part of the historical background needed for effective handoff.

Near miss:

• Incident Report 1: The nurse identified the client's allergy before administering azithromycin, preventing an adverse reaction. Holding the medication and notifying the provider ensured patient safety, making this a near miss rather than an adverse event.

Adverse Event:

• Incident Report 2: The client did not receive prescribed prophylactic antibiotics during labor, leading to neonatal sepsis. The lack of antibiotic administration increased the risk of serious complications, making this an adverse event with potential long-term consequences.

• Incident Report 3: A tenfold dosing error led to the administration of 60 units instead of 6 units of insulin, resulting in severe hypoglycemia and unresponsiveness. This critical medication error placed the client at significant risk for neurological damage or death, classifying it as an adverse event.

• Incident Report 4: A critically low platelet value was reported but not communicated to the provider, delaying intervention and leading to a coma. The failure to act on critical lab results contributed to a preventable deterioration in the client’s condition, making this an adverse event.

• Incident Report 5: Despite being identified as a fall risk, the client sustained a fall due to a malfunctioning call bell, leading to an injury. The failure to address the defective equipment compromised patient safety, making this an adverse event that could have been prevented.