Case study
Case Study Option 2:
Mr Jeffries, a 76-year-old patient was admitted to the acute aged care ward of a hospital following a fall at home, where he injured both his wrists. He has a history of Type 2 diabetes mellitus and usually self-administers his insulin at home via an insulin pen TDS before meals.
The ward was very short-staffed for the morning shift due to staff absences (gastro out
eak), so RN Amanda was seconded from the paediatric ICU (PICU) department to work the morning shift on the acute aged care ward. Amanda had 30 years of PICU experience and had not looked after adults since her graduate year, however, she was happy to help out as she thought that working in aged care had to be much easier than nursing critically unwell infants.
Amanda introduced herself to Mr Jefferies and he asked her when he was going to get his insulin, so he could eat
eakfast. Amanda read the medication order and went to the treatment room to prepare the 2 units of Humulin. She was a bit confused because the medications and equipment were different to the PICU ones, but she drew up the insulin, checking carefully that she had the right patient, right time, and right medication against the medication order. She asked Agency RN George to check the prepared injection, and George glanced at the items in the kidney dish, checked the insulin vial to see that it read “Humulin” and the use by date and said it was all OK. Amanda proceeded to administer the insulin to Mr Jeffries and then continued with her busy shift.
An hour later Mr Jeffries rang the bell as he was feeling very unwell. He appeared anxious, confused, was tachycardic and sweating, so Amanda checked his BGL and it was 1.8 mmol/L. The MET team were called and after some emergency IV dextrose, Mr Jeffries was transfe
ed to HDU for monitoring. An incident form was completed and when questioned by the unit manager about the incident Amanda demonstrated that she had used a 3ml syringe to administer the insulin instead of an insulin syringe. The patient had received 2 mls (200units) of insulin instead of the ordered 2 units of insulin. The hospital Quality and Safety unit investigated this incident.
Root cause: medication e
or – inco
ect dose of medication administered to the patient.
Discussion of identified root cause.
1. Briefly discuss how the identified root cause has led to the outcome for the patient.
2. Identification and discussion of contributing factors
Discuss three (3) contributing factors that have likely led to this sentinel event.
Links to NMBA RN Standards for Practice
3. Identify and discuss two (2) separate NMBA RN Standards which were not practiced o
maintained by the nurse(s) involved in this sentinel event, that may have led to the identified
oot cause. You need to identify and discuss specific sub-standards (e.g. standard 7.2, not
just standard 7).
4. Links to National Safety and Quality Health Service (NSQHS) Standards
Identify and discuss two (2) separate NSQHS Standards which were
eached (or not met)
in this scenario, that may have led to the identified root cause. You need to identify and
discuss specific action items (e.g. Clinical Governance Standard, action 1.03).
5. Outline three (3) recommendations to address the contributing factors you identified from the chosen case study (from question 2), or the root cause. These recommendations need to include practical examples and identify who is responsible for actioning these recommendations.
-Recommendations to address contributing factors or root cause
-Practical example(s) to achieve
-recommendations.
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