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Available Feb 11 at 12am - Mar 8 at 11:59pm 26 days Not for IV Use: The Story of an Enteral Tubing Misconnection The Story of Robin and Addison Lowe (United States) LEARNING OBJECTIVES After completing this case study, you will be able to: 1. Explore the scientific feld of human factors and how errors like tubing misconnections can be prevented. 2. Discuss the complexity of having two patients to treat, a mother and her fetus. 3. Describe suitable actions by healthcare staff following the discovery of an error. 4. Discuss engineered forcing functions and how they can be used to make medical devices safer. INSTRUCTIONS Please read the below case study and answer the questions that follow with detailed specifics to support your answers. Please upload your Word document to your instructor for grading Background On July 18, 2006, my daughter Robin was admitted to the hospital. She was 24 years old, and she was 35 weeks pregnant. She was admitted for intractable pain, vomiting, and dehydration. It wasn't the first time Robin had been admitted to the hospital. She had had episodes with similar symptoms from the time she was 11 or 12 years old. She would have intense abdominal pain and would start vomiting. She would vomit 30 times a day. She would get dehydrated, of course, and so we would have to admit her to the hospital. The first summer it seemed like she was in the hospital every other week. The doctors finally decided it was an autoimmune syndrome that they had seen mostly in teenaged girls, and they just grow out of it. We tried allergy type treatments, which never

Answer 1

1.The nurse's negligence has led to the death of Robin and her fetus. The nurse didnot crosschecked the fluid before transfusion , nor didnot learn the orders of the physician clearly. Her failure to practice her ethics led to such a situation. According to the hospital orders the nutritionist has to check the TPN before infusion but even before that ,the nurse have started to infuse the solution.The enteral feeding usually comes attached with a feeding tube but this time it came without feeding tube which was also the reason for the sentinel event.

The nurse could have stopped this event, because there was no order for TPN or enteral feeding and also if she could have crosschecked with another nurse this error could have been prevented.When Robin's mother read the wordings(not for IV use) on the hanging bag at 1:00 , she should have asked the sister about the bag hanging and the solution or she should have enquired the physician about this .

The nurses should be given adequate education regarding critical thinking and advised to practice the international patient safety goals . Patient safety is the foremost goal to be fulfilled .

2. The chain of events like failure to keenly observe the fluid, lack of cross checking , failure to wait for the nutritionist, lack of following doctor's order ultimately were due to human error which lead to the sentinel event. The nurse, dietary department, hospital policies, physician everyone were responsible for the event. When Robin's mother was questioning about the baby's condition and ultrasound the nurse answered inappropriately. The nurse may be incompatible to the work environment.

Evidence based practice should be implemented . Patient safety and quality care should be anticipated. Nurses should be provided inservice training .

3. Glenda was already anxious about her daughter's condition and she was taking care her grandson too. When the healthcare professional is the patient or any of the family member is a patient , we are usually emotional and depressed .

4.Just culture discusses or explains the concept of the patient safety and safety culture .

This concept explains about three human behaviors leading to mistakes .They are

Human error - The mistakes which was not planned or consciously done.

At-risk behavior - The mistake occur when a person do something without knowing and understanding the effect of the act they do.

Reckless behavior - The mistake occurs due to utmost carelessness and hasty behavior.

These behaviors can be solved only when employees are trained, informed and provided information regarding effects of hasty behaviors and the possible disciplinary action which would be taken on them.

The nurse's reckless behavior led to the death of Robin and her fetus. If she was aware of the situation , Robin would have been saved.