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Mar 18, 2024

Assignment Task

Case Study

1. Mrs Bentley, an 84-year-old was admitted to the hospital for a routine total knee replacement (TKR). Mrs Bentley was alert and oriented before surgery, chatting with the nursing team and her pre-op observations were all within normal limits. Mrs Bentley’s surgery commenced at 1700hrs, two hours later than planned due to a complication with the previous patient in the theatre. The tired OT staff rushed to prepare for Mrs Bentley’s surgery and all the instruments were checked by Scrub RN Nicole, who quickly looked over the trays of instruments and stapled the paper instrument receipts from Clean Sterile Supply Department (CSSD) in the patient notes. Mrs Bentley’s surgery was uneventful, and she was transferred to post anaesthetic care unit (PACU). She recovered well, and the only issue was a slightly elevated temperature. The PACU nurse reasoned that this was probably due to post-op inflammation and noted this on the PACU report.

Mrs Bentley was transferred to the orthopaedic ward at 1930hrs, where she was received by RN Steve. Steve completed a set of initial post-operative observations, noting Mrs Bentley’s elevated temperature. Steve missed some scheduled post-op observations on Mrs Bentley as he was busy. When the night shift arrived at 2100hrs Steve handed over to RN Misha that Mrs Bentley was stable, had not passed urine since her return to the ward and her temperature remained elevated due to post-op inflammation, but it had been like this since PACU so was not reason for concern. Misha did a set of observations noting that Mrs Bentley still had a high temperature, her BP was a bit low and she gave Mrs Bentley an extra blanket as she was shivering. Mrs Bentley seemed a bit sleepy and confused to Misha, but Misha thought that this was normal considering Mrs Bentley’s age and documented “temp due to inflammation, low BP, wound dressing dry and intact, confused ? dementia” in Mrs Bentley’s notes. The night shift was very busy due to two staff calling in sick so Misha didn’t do any further observations on Mrs Bentley, only checking on her as she walked past the room noting that Mrs Bentley appeared to be sleeping.

When the morning shift arrived at 7 am Mrs Bentley was found semi-conscious, disoriented, moaning in pain. Her skin was clammy, and there was purulent ooze from her operation site. The MET team was called, and Mrs Bentley was transferred to ICU, where she was placed on assisted ventilation. She was also administered a large dose of IV antibiotics for suspected infection and had to return to theatre for further surgery to remove the infected prosthesis. She eventually recovered after a long hospital stay but had ongoing health issues. During the Infection Prevention and Control follow-up of Mrs Bentley’s critical.

The incident it was noted that two of the trays of instruments used in Mrs Bentley’s surgery were not sterile with the CSSD tickets in her notes stating "steriliser cycle incomplete”.

2. Mr Jeffries, a 76 years-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 outbreak), 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 breakfast. 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 transferred 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.

1. Discussion of identified root cause

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.

3. Links to NMBA RN Standards for Practice

Identify and discuss two (2) separate NMBA RN Standards which were not practiced or maintained by the nurse(s) involved in this sentinel event, that may have led to the identified root 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 that were breached (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).

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