NRSG378 Assessment 1– Project RCA Case Study ...

Case Study Option 1: 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 (200 units) of insulin instead of the ordered 2 units of insulin. The hospital Quality and Safety unit investigated this incident. Root cause: medication error – incorrect dose of medication administered to patient.

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