• If requested by the Supervisor, the student group will have to present their activity log to the
whole class.
• The Supervisor may comment on the presented daily activity logs and provide feedback.
• If the Supervisor provides feedback to a group, they MUST record the instructor's feedback
and submit it with their daily log.
• If requested by the Supervisor, the student group will have to present their weekly
deliverable. This daily session-based feedback will ensure students' work is constantly evaluated.
WIL PROJECT CASE STUDY ORIENTATION WEEK 1
Applicable VLOs for This Week’s Case Study
1. Explain how system failures can lead to patient harm.
This Week’s Detailed Case Study Information
You are a physician making rounds on your patients when you arrive at Mrs. Buckman’s room. She’s
an elderly lady in her late 70s who recently had colon surgery. She is also the wife of a prominent
physician at the hospital. She has been known to be somewhat contentious with the nursing staff.
However, today she states she was just given a shot of insulin to cover her elevated blood sugar, and
the amount of insulin did not seem to be the usual amount. Even though Mrs. Buckman often
complains, you are somewhat concerned about this observation and decide that it would be best to
check on this.
You ask the charge nurse to review the dose of insulin given. She, in turn, finds Mrs. Buckman’s nurse,
who states that, as ordered, she had given the patient 80 units of insulin. You immediately become
pretty alarmed, as this is a substantial dosage. You ensure that the patient is given a large amount of
glucose supplement and that her blood sugar is monitored every 15 minutes for the next two hours. To
follow up, you also review the chart and note an order from the house physician to give Mrs. Buckman
8.0 units of insulin. You can readily see how this could quickly appear to be 80 units.
You meet with the charge nurse, the nursing supervisor, the Director of Nursing, and the
treating nurse to determine what can be done to prevent this type of error in the future.

Can you suggest system process improvements that might reduce the likelihood of similar
errors in the future?

Question

• If requested by the Supervisor, the student group will have to present their activity log to the
whole class.
• The Supervisor may comment on the presented daily activity logs and provide feedback.
• If the Supervisor provides feedback to a group, they MUST record the instructor's feedback
and submit it with their daily log.
• If requested by the Supervisor, the student group will have to present their weekly
deliverable. This daily session-based feedback will ensure students' work is constantly evaluated.
WIL PROJECT CASE STUDY ORIENTATION WEEK 1
Applicable VLOs for This Week’s Case Study
1. Explain how system failures can lead to patient harm.
This Week’s Detailed Case Study Information
You are a physician making rounds on your patients when you arrive at Mrs. Buckman’s room. She’s
an elderly lady in her late 70s who recently had colon surgery. She is also the wife of a prominent
physician at the hospital. She has been known to be somewhat contentious with the nursing staff.
However, today she states she was just given a shot of insulin to cover her elevated blood sugar, and
the amount of insulin did not seem to be the usual amount. Even though Mrs. Buckman often
complains, you are somewhat concerned about this observation and decide that it would be best to
check on this.
You ask the charge nurse to review the dose of insulin given. She, in turn, finds Mrs. Buckman’s nurse,
who states that, as ordered, she had given the patient 80 units of insulin. You immediately become
pretty alarmed, as this is a substantial dosage. You ensure that the patient is given a large amount of
glucose supplement and that her blood sugar is monitored every 15 minutes for the next two hours. To
follow up, you also review the chart and note an order from the house physician to give Mrs. Buckman
8.0 units of insulin. You can readily see how this could quickly appear to be 80 units.
You meet with the charge nurse, the nursing supervisor, the Director of Nursing, and the
treating nurse to determine what can be done to prevent this type of error in the future.

Can you suggest system process improvements that might reduce the likelihood of similar
errors in the future?

Accepted Answer

System improvements that could be made to reduce such types of errors in future could be setting…