Question

QA Case B On February 24, 2010, Joe Blow filed a QA complaint against Montuck Medical Center (MMC), which was subsequently reviewed by the Quality Assurance officer of the Medical Center. Joe Blow was a thoracic surgeon at MMC at the time of the complaint. The complaint alleged that, while his wife, Nancy Blow, was a patient at MMC with complications of end-stage cancer, she received nursing care that fell below the applicable standard of care and resulted in her early demise. Facts of the case: On February 10, 2016 Ms. Blow was admitted to the oncology floor at MMC. Ms. Blow had been treated for stage 4 colon cancer for the last three months with chemotherapy and radiation. She had a Hickman Catheter (a tunneled central line) inserted with the exit site directly under the xiphoid process for chemotherapy and blood draws. Because of increased pain and malnutrition associated with cancer therapy, she was admitted on February 10 for insertion of a jejunostomy tube (J tube) for feeding and for pain management with Morphine (liquid form through J tube). The J tube was inserted on February 11 with an exit site in the left upper quadrant of the abdomen. The J tube was patent and used for intermittent supplemental feedings and for pain management as of February 12. On February 14, Amy Chan, the registered nurse who was assigned to Ms. Blow for the day shift, received report on Ms. Blow at 0700 from the previous shift nurse. The previous shift nurse noted that Ms. Blow had had a difficult night with pain management and had required the medication around the clock to control her pain. The presence of both the Hickman catheter and the J tube was mentioned in the report. Ms. Chan entered Ms. Blow’s room at 0800 for the initial assessment. Vital signs were within Ms. Blow’s normal limits, and Ms. Chan documented that Ms. Blow was at a pain level of 4 at this time. There was no documentation of either the Hickman catheter or the J tube. At 0900, Ms. Blow signaled the front desk that she needed something for pain. Ms. Chan reported to Ms. Blow’s room and found the patient to be in moderate distress with a reported pain level of 9/10. No vital signs were checked at this time. Ms. Chan returned to Ms. Blow’s room at 0930 with the ordered liquid Morphine in a syringe and water to flush the J tube before and after the pain medication. Upon identifying the J tube, Ms. Chan attempted to check placement and flush the tube but was unable to flush the tube. Knowing that Ms. Blow was in significant pain, Ms. Chan was anxious about giving her medication. She saw the Hickman catheter, and deducting that the exit for that catheter was very close to the exit for the J tube so must be going to the same place, flushed the Hickman catheter with water and inserted the liquid Morphine through the Hickman catheter. Within 10 minutes, Ms. Blow was cyanotic and in cardiac arrest. The code team was called but, upon arrival, was not able to revive Ms. Blow. She was pronounced at 1000 on February 14. Facts from the QA investigation: Ms. Chan had been a registered nurse for 8 months. After passing her State Board NCLEX and getting a license, she was hired to work on the oncology floor at MMC. The hospital provides 3 months of orientation for new employees. On the oncology, the nurse manager (NM), Missy Little assigned Ms. Chan to Octavia Major for the 3-month orientation. There was no formal format for nursing orientation on the unit. After 3 months, Ms. Major did not feel that Ms. Chan was ready to work by herself and recommended another 2 months of orientation. Because Ms. Chan had not progressed as expected under Ms. Major, NM Little assigned her to another preceptor, Matthew Broderick, for the next 2 months. NM Little, Ms. Major, and Mr. Broderick discussed areas where Ms. Chan needed improvement and a sketchy plan was developed for the continuing orientation. Ms. Chan progressed better under the direction of Mr. Broderick and, at the end of two months, Mr. Broderick noted that she would probably be okay on her own with support from the team but was not completely comfortable with releasing her from orientation. A decision was made by NM Little, because of the time Ms. Chan had already been in orientation and the progress she had made with Mr. Broderick, to take Ms. Chan off orientation. Ms. Chan was informed of this decision and was instructed to seek assistance from the charge nurse on the unit for any situation she was not sure about. Ms. Chan had been off orientation for approximate 2.5 months at the time of the incident. Although Ms. Chan continued to be disorganized and had problems with time management, no major problems in her performance were documented during this time. When questioned, Ms. Chan had not asked for assistance in this case. She had not taken care of a patient with a Hickman catheter during her orientation or since being taken off orientation. She did not remember being taught about different central lines in nursing school. On this particular unit, patients with Hickman catheters were seen infrequently, on average one patient every 3-4 months. The different catheters that might be seen on the unit were not addressed in orientation. She thought she could handle the situation because the exit for the two tubes were close so they were obviously going in the same place. Ms. Chan was extremely distressed about this incident and plans on leaving the nursing profession completely. At least one significant post per group member in discussion group associated with the QA Analysis. Analyze QA scenario for all issues that led (or might have led) to the issue in the scenario for this patient. Identify standards of care/Nurse Practice Act, other resources involved with the specific QA analysis.

Answer 1

Quality assurance complaint in this scenario is inadequate nursing care below standard level..in this scenario there is inadequate catheter care( Hickman catheter and jejunostomy catheter)..poor documentation about pain management ..when patient was in pain there is no vitals has been checked..poor management and communication when they need any help with coworkers... inadequate knowledge and skills about Various Catheter management..

The nursing practice Act includes standards of care and administration of medication and providing Evidence based treatment for avoiding malpractice and harm to patient and high risk complications..board of nursing investigation act includes the violation of nurses..Quality Assurance analysis involved in this scenario state and territory board of nursing included the processes of filling complaint against when there is negligence, malpractice, unsafe and incompetent behaviour..

Standards of care for registered nurse should follow the rules and regulations..safe,competent,nursing practice mentioned in standards of practice under laws..out includes disciplinary action and their responsibility when it should be applied for critically ill patients..