Question Answered step-by-step Leadership and Management Case Study Number 3 Read the case… Leadership and Management Case Study Number 3Read the case information below:Mary, a new graduate Registered Nurse (RN) worked on a Telemetry Unit. This particular hospital has not yet converted to Computerized Physician Order Entry (CPOE) therefore, the physicians still hand write their patient care orders. Mrs. Betty Smith in Room 404 is a patient admitted with Congestive Heart Failure. This patient was ordered to receive 40 mg of Furosemide (Lasix), IV, every 12 hours. When Mary reviewed her physician order, the physician had used unapproved abbreviations and wrote “Lasix 40.0 mg IV every 12 hours. The hospital policy listed a trailing zero an unacceptable abbreviation, and it should be written only as 40 mg. Mary unfortunately could not read the decimal point in the dose and read the order as 400 mg. Mary did not verify the order with another nurse or charge nurse. She went to the Automated Medication Dispensing cabinet without her medication administration record (MAR), and overrode the pharmacy warning to only pull 1 40 mg vial, and instead pulled 10 vials (400 mg) and administered it. Mrs. Smith began urinating large amounts of urine and started to complain of severe leg cramps. About two hours later the cardiac monitor technician called Mary to inform her that the patient was having frequent Premature Ventricular Contractions (PVC’s) and bursts of Ventricular Tachycardia (VT). The patient then went into cardiac arrest, attempts were made to resuscitate the patient, and the patient subsequently expired. The family was notified of the death, the house supervisor was notified, and the patients primary physician. Upon review of the patients chart the next morning, including the previous day’s medication documentation, it was discovered that Mary gave 400 mg of Lasix instead of 40 mg. You are the nurse manager that conducted a thorough review of the event, and also found that the patients Potassium at the time of the event was only 3.0.Questions:1. As the nurse manager please document all of the events including errors that led to this patient event.2. Please discussed unapproved abbreviations in patient care. Provide scholarly support for your discussion from current peer reviewed journals.3. Should Mary be terminated for her medication error? Why or why not? Please Research “Just Culture and list the components to determine if this was an intentional or unintentional event.4. Would you allow Mary to work until the investigation was complete? Do you believe that Mary is an unsafe nurse? Why or why not? Explain and support with evidence.5. Please review reportable sentinel events in California. Discuss if this event had to be reported to the California Department of Public Health (CDPH). Discuss reporting of sentinel events.6. Sentinel events have to be disclosed to the patient’s family. How would you do this? Who would you have with you as the manager when you disclosed this information? Would you disclose it, or have the physician or the hospital risk manager disclose this event? Health Science Science Nursing NURSING 402 Share QuestionEmailCopy link Comments (0)
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