Mr B Root Cause

"The toxicology studies on blood reveal the presence alprazolam, and amphetamine at levels likely consistent with the therapeutic range, a metabolite of buproprion and a high level of fentanyl. Phenylpropranolamine and amphetamine are present in the urine. When fentanyl and alprazolam are taken together there may be a synergistic central nervous system depressive effect. Based on the history and circumstances, s currently known, the manner of death is accident."

Additionally, the care environment developed a hazard when the patient population increased both in number and acuity with the admission of the acute respiratory distress patient and increasing patient load in the lobby without note of available back up staff being called in. Examples of errors from the flow chart comparison might include failure to assess and monitor when Nurse J initiates blood pressure and SpO2 measurements, fails to initiate ECG with respiration monitoring, fails to administer supplemental O2, and leaves the room without apparently noting the baseline of the patient2. Furthermore, there appears to be an error in the lack of communication collaboration between the RN and LPN regarding Mr. B’s post procedure status and monitoring needs, and there is a failure to rescue when the LPN notes the low SpO2 value, fails to respond, and instead re-initiates another blood pressure reading without noting the results. As Mr. B’s condition deteriorates and a code is called, an ACLS error is observed in the timeline when the patient is noted first to have absent pulse and respirations and that a monitor is next applied and the patient and displays ventricular fibrillation. Chest compressions appear to not have been the first action in this scenario, nor is end tidal CO2 monitoring noted as initiated to monitor the quality of compressions. These are examples of hazards and errors in the care of Mr. B and in an actual RCA the level of detail would likely turn up

We then look at the errors of hazards that occurred in the Mr. B scenario.  Though we can say understaffing may have contributed to Mr. B’s demise, we cannot blame understaffing. This scenario is regrettably connected to inattentive nursing practice. It is clear that respiratory therapist was in the building and

In 2017, up to November 11th, 580 emergency calls were placed regarding opioid-related overdoses in the Waterloo Region (1). Thus, the running total of calls in 2017 as of November 11th is already one-hundred and fifteen percent of the total calls for the 2016 year (1). From the year 2012, opiate-related overdose calls have raised three-hundred percent (1). Consequently, the issue of opiate overdose is clearly an important one.

Elliott, M., Page, K., and Worrall-Carter, L. (2012). Reason’s accident causation model: Application to adverse events in acute care. Contemporary Nurse, 43(1), 22-28.

Lack of situation awareness by the nurse and failure to use the SBAR protocol when on the phone to the cardiologists.

The scenario was alarming yet gave a realistic view on how non-adherence of procedure, breakdown of communication and the lack of accountability became the triggers for this sentinel event. Since 1996 the Joint Commission as instituted a sentinel event policy that enables hospitals to evaluate and implement corrective action that will reduce future risk (Sentinel Event Policy and Procedures, 2014). My role as the medical student was significant to the outcome because I was medical aware of abnormal changes however not confident enough in my abilities to be an advocate for the patient. Evidence of the patient status through data trending would have provided the support I need to contact the attending physician. The inability to follow proper hospital procedure related to aseptic techniques was the first of many problems.

For statistical purposes, prescription harm will be solely measured by the prescription overdose deaths in my study. The other types of prescription harm discussed, including extensive drug effects and drug-related emergency department visits, are either estimated values or moderately controversial on the source of the harm. Additionally, statistical evidence and conclusions made based on overall prescription data would hold little validity due to many extraneous factors that differ from one medication to the next; therefore, I will focus exclusively on opioid analgesics, a common prescription for chronic pain relief.

Pulmonary embolism resulting from deep vein thrombosis is the most common preventable cause of hospital death (Maynard, 2015). Consequently, the Surgeon General has called to action to prevent deep vein thrombosis. Deep vein thrombosis in the healthcare setting can be reduced through

The U.S. Department of Health and Human Services (HHS) (2013) reported that U.S. prescription drugs, especially opioids analgesics, have been increasingly involved in drug overdose deaths. Unfortunately, drug overdose deaths from prescription drugs, especially opioids analgesics outnumbered deaths related to motor vehicle accidents back in 2009. Actually, in 2010 only, 16,651 deaths were connected to opioids overdose, an increase of 60 percent of overdose losses from any other drug class, prescribed or illegal. Specifically, in Florida, the attorney general of Florida (2012) stated that an average of seven Floridians die every day as a result of overdose from prescription drugs, which is five times greater than losses from the use of all illegal drugs put together.

Opioid use in the US has increased over the years, and this has led to an increase in substance abuse. Substance abuse is not only associated with use of illicit drugs but also prescription drugs. In 2015, of the 20.5 million reported cases of substance abuse, 2 million had an abuse disorder related to prescription pain relievers and 591,000 associated with heroin.1 The increase in substance abuse disorder has led to an increase in opioid related death. In 2015 drug overdose was the leading cause of accidental death in the US with 52, 404 lethal drug overdoses.2

Opioid drugs are some of the most widespread pain medications that we have in this country; indeed, the fact is that opioid analgesic prescriptions have increased by over 300% from 1999 to 2010 (Mitch 989). Consequently, the number of deaths from overdose increased from 4000 to 16,600 a year in the same time frame (Mitch 989). This fact becomes even more frightening when you think about today; the annual number of fatal drug overdoses in the Unites States now surpasses that of motor vehicle deaths (Alexander 1865). Even worse, overdose deaths caused by opioids specifically exceed those attributed to both cocaine and heroin combined (Alexander 1865).

The patient did not receive standard treatment to prevent the formation of a DVT. What are some possible reasons why this error occurred? The first reason was that the nurses and staff on the floor were so focused on his admitting problem being related to COPD, which caused his respiratory infection, which then caused his kidneys to not function properly. Since his kidneys were not up to par, the staff wanted to make sure that he was not going to go into kidney failure, so that was their number one priority at the time. Secondly, the admitting doctor did not order DVT (deep vein thrombosis) prophylaxis. Based on his thrombosis risk factor assessment, the patient would have scored as a high risk. He should have been placed on sequential compression devices (SCD), and either heparin or lovenox (University of Michigan Health System, n.d.). The most alarming reason was that the nurse did not

As Jane was presenting with a symptom of a life threatening event it was important that treatment was immediate. Priority was initially made from assessment of the airways, breathing and circulation, level of consciousness and pain. Jane’s respirations on admission were recorded at a rate of 28 breaths per minute, she looked cyanosed. Jane’s other clinical observations recorded a heart rate of 105 beats per minute (sinus tachycardia), blood pressure (BP) of 140/85 and oxygen saturation (SPO2) on room air 87%. It is important to establish a base line so that the nurse is altered to sudden deterioration in the patient’s clinical condition. Jane’s PEWS score (Physiological Early Warning Score) was 4 and indicated a need for urgent medical attention (BTS 2006). Breathing was the most obvious issue and was the immediate priority.

Pulmonary Embolism is a life-threatening condition that has most serious manifestation of venous thromboembolism that is leading cause of sudden death. “With massive pulmonary embolism (PE) being the first or second leading cause of unexpected death in adults, protection against PE is critical in appropriately selected patients” (Georgiou, Katz, Ganson, Eng, & Hon, 2015). How does this effect the nursing? If Pulmonary embolism is suspected, nurses goal is to halt PE that is forming a clot and from embolizing. Nurses must be extra diligent in preventing Pulmonary embolism, be able to recognize it early, provide prompt help and start appropriate treatment because if it is unrecognized or untreated it can cause death very quickly. Knowing how to intervene when PE is suspected can make a difference in life a threatening emergency. “Massive PE, defined as causing 50% or more occlusion of the pulmonary capillary bed, can result in obstructive shock with systemic hypoperfusion (low cardiac output and acute pulmonary hypertension with right ventricular failure). ANA’’.