Luna was a 77-year-old resident who was returning to the nursing home on 10/4/19 from the hospital following a left hip fracture
Luna was a 77-year-old resident who was returning to the nursing home on 10/4/19 from the hospital following a left hip fracture. Before her fall, Luna had been a resident of the nursing home for only a week when she sustained the fracture. She has a history of diabetes and hypertension. BP 143/90, HR 90, RR 20.
Luna’s transfer form from the hospital included an order for Lasix as well as several new medications. Lasix was part of her original nursing home medication list before being transferred to the hospital. All medication orders from the transfer form were re-written on the new Medication Administration Record (MAR), but the old MAR from the previous stay was not removed. When the nurse checked the new orders, she mistakenly interpreted the new Lasix order on the MAR as an unintentional duplication in transcription and yellowed out the line on the MAR. She was interrupted to take a phone call and did not complete the process of checking the new orders. She asked another nurse to complete the process. The second nurse completed double-checking the orders and noted the old MAR was still present. She removed the old MAR and let the first nurse know she had completed the task. The nurse who was passing medications noted the line for Lasix had been yellowed out, which she interpreted to mean the medication was discontinued. She was the same nurse who passed the medications on the unit for three days in a row. On 10/6/2019, having interpreted that the medication was discontinued earlier, removed the Lasix from the medication cart to be sent back to the pharmacy. It was picked up to return to the pharmacy on 10/7/2018.
Luna was weighed on November 8th with a noted 3 lb. weight increase from admission. The weight was recorded in her chart with an indication that a call would be placed to Luna’s physician. No new orders were recorded following that entry. On 10/08/19, at 2 a.m., Luna was noted to be having extreme difficulty breathing. She had +4 pitting edema, BP was 200/120, HR 130, RR 29. Her lungs were assessed and were moist with crackles throughout. The attending physician was called. The physician ordered Luna to be transferred back to the hospital. While awaiting the ambulance, Luna went into cardiac arrest and could not be resuscitated
Q1. What do you think about the quality & safety of Luna’s health care? Was harm incurred?
Q2. What are the responsibilities of the nurses in the case?
Q3. Can you suggest system process improvements that might reduce the likelihood of similar errors in the future
Collepals.com Plagiarism Free Papers
Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.
Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS
Why Hire Collepals.com writers to do your paper?
Quality- We are experienced and have access to ample research materials.
We write plagiarism Free Content
Confidential- We never share or sell your personal information to third parties.
Support-Chat with us today! We are always waiting to answer all your questions.
