Description
Case Study #1
A 55-year old female was transported to the floor after recovering from a surgical procedure. An epidural catheter with morphine was placed for post-operative pain control. Upon arrival, the patient complained of nausea and a headache prompting the on-call physician to prescribe, “Demerol 75mg every three hours for pain.” The preprinted medication orders from anesthesia stated “No narcotics, sedatives, or other respiratory depressants to be given during infusion of epidural medication and for 12 hours after epidural is discontinued except by order of anesthesia.” The nurse had not reviewed this order prior to obtaining and administering the new order for Demerol, a narcotic.
Twenty minutes later, the patient was found unresponsive and aggressive resuscitation efforts were implemented, resulting in intubation and mechanical ventilation of the patient. When brain activity was not found, the family made the decision to take the patient off of life support and the patient died shortly thereafter.
The patient’s family filed a lawsuit claiming negligence in administering the medication. A verdict was entered against the nurse for nearly $4 million.
- Event Identification
- Risk Assessment Reference
- Response Plan
- Control Activities
- Information and Communication
- Monitoring
- Recommendation
- Conclusion
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Explanation & Answer
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Health & Medical
Institution Affiliation
Student’s Name
Course code: Code Name
Professor’s Name
Due Date
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Introduction
There is always the potential for adverse outcomes in every given situation. As a result,
to manage these risks and decrease the impact they could create, special policies and processes
must be implemented to ensure that risks are avoided or that their influence is reduced to a larger
degree. In light of this, risk management is the act of discovering, assessing, and controlling
threats an entity can face due to unforeseen risks (Yusyanti, 2021). This is done to protect the
business from potential adverse outcomes. These adverse outcomes can potentially destroy an
organization's reputation and lead to expensive lawsuits and loss of revenue for an entity.\
The health industry is most likely to be affected when it comes to exposure to risk daily.
This is primarily because the fates of a significant number of individuals are in the hands of the
nurses and doctors who provide treatment. As a result, the hospital is held responsible for any
clerical error that can bring about a complication that jeopardizes many people’s lives. In light of
the fact that this occurs virtually every day, there needs to be a robust system to ensure that the
risk of fatalities is reduced as much as possible, if not eliminated( McMichael, 2022)... This is
accomplished by steadfast adherence to the ethical code and the pledge taken by Hippocrates.
Therefore, by making the patient’s well-being the priority, the risk to the patient will be reduced
to a significant but manageable degree.
This article will present a case study on a 55-year-old woman who passed away due to a
clerical error made by the nurse. The mistake led to the wrong medication being administered to
the patient, ultimately leading to her death. The family has filed a lawsuit against the nurse for 4
million dollars. In light of this, the following will be discussed in this article: the risk factor; how
the situation could have been handled instead; the response plan; information and
communication channels; and what would have been done differently at the time and in the
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future to ensure that similar situations are prevented and do not occur again. This is also being
done to reduce the likelihood of the risk arising at some point in the future and possibly laws
suits.
Event Identification
In the case study shown, the patient is a 55-year-old woman who underwent surgery.
Following the procedure, the patient was transferred to the care of a nurse and given specific
instructions to follow to recover as quickly as possible. An epidural catheter containing morphine
was intended to control the patient's discomfort after surgery. Nevertheless, when the patient was
moved from the operating room to the recovery room, she reported feeling nauseated and having
a headache. In response, the attending physician suggested that she be given 75 milligrams of
Demerol every three hours to treat the headache and nausea. This was in contrast to the
preprinted medication orders from anesthesia, which clearly stated, “Except narcotics, sedatives,
or any other respiratory depressants, and for twelve hours after the epidural has been removed,
except being under the control of anesthesia.
However, after giving the patient the narcotic Demerol, the attending nurse did not
review the preprinted medication orders from anesthesia. This occurred after the nurse had
already provided the patient with the medication. Because of this, the anesthesia's
recommendations were automatically disregarded, and as a direct consequence, the patient
became unresponsive after twenty minutes. Since nothing could be done to resuscitate her, and
no activities were recorded in the brain, her family was forced to remove her from the life
support equipment and sue the nurse for over 4 million dollars in damages for negligence.
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Over this, the case study presents a scenario in which a fatality could have been
prevented if appropriate lines of communication had been utilized( McMichael, 2022)... Because
situations like death cannot be undone, families who have lost a loved one often turn to the legal
system to seek retribution and compensation for their losses and anguish.
Risk assessment reference
In healthcare, risk assessment refers to taking precautions. One is conducting an
exhaustive inquiry into the surrounding environment that could potentially put patients at risk for
injury or illness. This is done so that appropriate preventative measures can be taken. According
to the case study in question, the pain and difficulties that might follow from surgery, if they are
not correctly treated, can result in a risk that can cause and affect death in patients. The patient,
who was 55 yea...