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MC is a 67 year old is a teacher’s assistant at a local elementary school. The patient presents to the hospital for a laparoscopic bladder neck suspension to correct a long standing history of urinary incontinence. All pre-operative diagnostic tests are within normal range. She is cleared for surgery by the attending physician and anesthesiologist. Consent for surgery is signed by the patient. Admission Nursing Assessment Past Medical History Gastrointestinal reflux Hypothyroidism Stress Incontinence Hysterectomy No history of smoking/substance use Current medications Levothyroxine 100mcg; one by mouth every day Multivitamin; one by mouth every day General Appearance Subjective: “My name is MC and my birthday is 11/14/50. I am a little anxious about all this.” Objective: Well developed, well-nourished female who appears stated age; Grooming, behavior, and speech are appropriate for situation; Cooperative with exam, appropriate eye contact and expressions. Awake, alert, and oriented to person, place, time, and situation. Vital Signs Oral Temperature: 98.6 F (37° C) Blood pressure: 130/70, Left arm Respirations: 20, regular Apical Pulse: 98, regular Weight: 120 lbs. (54.4 kg) Height 5’4″ in (163 cm) Skin Subjective: none Objective: Skin white, warm to touch, good skin turgor; no lesions; nails without clubbing or deformities, pink; capillary refill < 3 secs. Head and Face Subjective: none Objective: Hair fine, brown with gray patches; distribution appropriate for age; normocephalic; face symmetrical without drooping, no involuntary movements. Eyes/Ears Subjective: "I have worn glasses all my life." Objective: PERRLA, glasses noted. No ptosis, conjunctiva clear; brows, lashes present with appropriate distribution; External ear without masses, lesions, or tenderness; position and alignment appropriate Nose/Mouth/Throat Subjective: "I have seasonal allergies, but not bad." Objective: Teeth in good condition, tongue protrudes midline, throat mucosa pink, uvula rises with phonation; tonsils present; gag reflex present. Neck Subjective: none Objective: Neck supple with full ROM, no pain. No lymphadenopathy, trachea midline; carotid pulses 2+/equal bilaterally. Chest/Breasts Subjective: "I do not have any pain or discomfort in my chest." Objective: Chest expansion symmetric, relaxed; Breath sounds clear bilaterally, no adventitious breath sounds; Breast exam deferred. Heart Subjective: "I have never had any heart problems. I do have high cholesterol." Objective: Apical impulse noted at 5th intercostal space, left midclavicular line. S1 and S2 sounds auscultated; no extra heart sounds, no murmurs noted. Abdomen Subjective: "I do not have any stomach pain." Objective: Flat, symmetric with no apparent masses; skin smooth with few striae; no lesions. Bowel sounds present all quadrants, no bruits. Abdomen soft to palpation; no organomegaly; no masses. Genitourinary Subjective: "My bladder has been leaking for years. Since I had a hysterectomy several years ago, I have been dealing with this. I am now using about 2-3 pads an hour. It smells and I just do not want to deal with it anymore." Objective: Mild tenderness noted over the suprapubic region on palpation. Urine soaked pad noted in patient bathroom with strong urine smell. Musculoskeletal Subjective: None Objective: Moves all extremities with full ROM. Neurologic Subjective: None Objective: PERRLA; Glasgow Coma Scale=15. Speech clear; tongue midline; gag reflex intact; soft palate and uvula move up midline when patient states "Ahh" Surgery MC was transported to the surgery department via stretcher without incident. The preoperative, intraoperative, and immediate post-operative periods were uneventful. According to the client's surgeon, "everything went well." MC was re-admitted to the medical surgical unit with the following orders: Post-op orders: NPO until awake, then progress to clear liquid as tolerated Post-op vital signs per protocol Normal Saline 0.9 at 125cc/hr Foley to gravity drain Pain: Demerol 50-75mg IM or IV q 4-6hrs prn pain and Phenergan 12.5-25mg IV q 4-6hrs prn nausea Post-operative admission to medical-surgical unit MC arrives to the room via stretcher, accompanied by the surgical nurse within one hour after surgery. MC experiences residual effects from anesthesia, and answers questions with incomprehensible speech. The nurse checks the patient's arm band, but does not replace it with an armband that identifies the new room number. MC is placed on a monitor, which is programmed to take BP, HR, and pulse oximetry every 15 minutes; the alarms are not set for this machine. The patient's daughter sits in the corner of the The influence of human factors in medication errors: a root cause analysis Dr. Robyn Caldwell FNP-BC, CNE 4 r..4@aum.edu room, near the window. She has no medical training, but does observe the nursing care being provided. The nurse leaves the hospital room, stating "I'll be back to check on you in a few minutes." The daughter reassures MC, who responds by nodding. MC asks for pain medication and holds her lower abdomen. The daughter notifies the nursing staff. Post-operative Nursing Assessment Jarvis, C. (2012). Physical Examination & Health Assessment (6th Ed). Elsevier BP 102/56, lying Apical HR 102, regular RR 14, regular Oral Temperature 98.8 F Pulse oximetry: 93% room air Neurologic Objective: Opens eyes to pain briefly, groans intermittently; Glasgow Coma Scale=10 Chest Objective: Chest expansion symmetric, relaxed; Breath sounds clear bilaterally, no adventitious breath sounds Heart Objective: Apical impulse noted at 5th intercostal space, left midclavicular line. S1 and S2 sounds auscultated; no extra heart sounds, no murmurs noted. Abdomen Objective: Flat, symmetric, bowel sounds present all quadrants, no bruits. Abdomen soft to palpation; no organomegaly; guarding noted to light palpation Genitourinary Objective: Catheter #16Fr draining yellow, clear urine. Tenderness in suprapubic region on palpation. Pain Subjective: moaning; "pain" Objective: patient unable to identify pain level on 0-10 scale; speech incomprehensible The nurse checks the written post-op orders and returns to the room with Demerol 75mg IV and Phenergan 25mg IV in a single 3cc syringe. The nurse administers the medication and leaves MC's hospital room, stating she would "check back in a bit." The daughter remains at her bedside. Within 5 minutes of receiving the medication, MC is snoring. The blood pressure The influence of human factors in medication errors: a root cause analysis Dr. Robyn Caldwell FNP-BC, CNE 5 r..4@aum.edu monitor continues to collect data, but no one returns to assess the patient. The nurse returns 1 hour and 11 minutes after administration, and MC has stopped breathing. Resuscitation efforts are initiated and MC is transferred to the intensive care unit. Intensive care unit MC is admitted to the intensive care unit, where her husband and son observe the nursing care being provided. Her husband displays a flat affect, with intermittent pacing. He rarely speaks and stares down at the tube protruding from his wife's mouth, while frequently looking up at the cardiac monitor. MC's brother, an emergency department physician (and only sibling) is present, accompanied by his daughters, who are nurses. 24 hours later MC is on a ventilator for 24 hours. The attending physician reports that the EEG (electroencephalogram) shows no brain activity. The family decides to take the patient off the ventilator, and she dies peacefully with her family at the bedside. The physician requests an autopsy, but the family declined, stating "what does it matter, she is gone." Hospital administrators along with risk management executives are called after the family asks to see MC's medical records. The request is denied. Administrators and staff are elusive about events leading up to her death. MC's daughter and son are told that "she had an episode called a PE (pulmonary embolism) and sometimes that happens after surgery." The administrator immediately begins to discuss a settlement with the family members. Conclusion MC's husband is schizoaffective with mania. He is very intelligent, and earned a Master's degree in mathematics, prior to the onset of his mental disorder. MC has been his daily caregiver for 20 years. After her death, MC's husband lived alone for 4 years, with daily assistance from his daughter. He begins displaying confusion, and becomes noncompliant with his medication regimen. He wanders away from his home during the night, and is subsequently placed in a nursing home. MC's daughter feels responsible for "not knowing something was wrong with her mother." MC's brother rarely speaks of her death. The nieces continue to speak publicly about MC's death. This death could have been prevented, and the implications are far-reaching. Once the medication has been administered, there are no "do overs." THINK before you act, the consequences last forever. Discuss the nurse's role in the outcome of this case study. What nursing factors are relevant to the outcome What factors possibly influenced the nurse's decision to give the medication as ordered? Explain. Should the physician be held accountable for his role in the outcome of this patient? Explain.

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