Case study: Medical Error
Links to an external site. and scroll down to the case study for Medical Error.
Watch the video and take notes about what you see that should have been done differently by the nurses in the case study.
The following information given in the report should help with understanding details in the scenario.
“Here’s Mr. Waters. We are so crazy in the Emergency Department, we’re on reroute! I’m bringing you another patient as soon you get him settled. I got the admission database done for you, and his orders are written. He’s 65, allergic to Levaquin, fell at home, and has an 8 cm laceration on his left arm. Kerlex dressing is dry and intact. History of atrial fibrillation, hypertension, coronary artery disease. Admitting diagnosis is syncopal episode. Vitals for me were blood pressure 136/84, temperature 37C, pulse 98 and irregular, respirations 20 and lungs clear, oxygen saturation is 98% on room air. He’s got a 22-gauge saline lock in the right arm. Everything else is fine. Oh—here’s his meds. I got them out but didn’t have time to give them. Thanks! I’ll be back in about fifteen minutes.”
Vital signs upon admission to the room: BP 130/78 – 104 – 18 – 98%
Medications he’s being given: Lipitor (cholesterol), Norvasc (blood pressure), Coumadin (thins blood)
Vital signs repeated 30 minutes later: BP 90/50, pulse 130
Labs drawn at the doctor’s office that morning: INR 4.3
Doctor’s order given: Vitamin K 10 mg subcu stat
Initial Post
Write your thoughts on better nursing practice to avoid any errors in the patient’s care.
Questions to consider include:
Were there any specific medication administration guidelines that were done incorrectly?
How did you feel throughout the simulation experience?
Could the nurses have handled any aspects of the simulation differently?
If you were able to do this again, how could you have handled the situation differently?
What did you feel was the primary nursing diagnosis and/or collaborative problems?
What were the key assessments and interventions?
