Subject Code & Title: NUR3605 Sentinel Event For Nurse
Mandy Andrews aged 19 (49 kg) returned to the ward after an emergency laparotomy for a ruptured appendix at 2010 hrs. Observations on RTW ward; BP 104/56m m hg, HR 52 and regular, RR 14 BPM, pain is 3/10, drowsy but rousable and orientated.
NUR3605 Sentinel Event For Nurse Assessment – Australia.
Post op orders include:
• Nil by mouth until reviewed by surgeons
• Continue IV fluids as charted (Hartman’s at 80 mL per hour)
• Routine post-operative observations
• Analgesia as required – Medication chart has prescription for Morphine 5 – 20 mg IV, Metoclopramide 10 mg IV
• No significant past history. Patients first hospital admission
Timeline of events:
At 2045 hrs Mandy complained of pain of 8/10 and was given Morphine 20 mg IV at 2055 by RN Smith (afternoon shift staff). The administration of the morphine was verbally handed over by RN Smith to the afternoon shift team leader RN Brown as RN Smith had to leave the ward to collect another patient from the operating theatre. The medication chart was not signed as it had been taken by the Doctor Blair (new resident) to prescribe IV antibiotics. As RN Smith had to leave the ward to collect another patient from theatre RN Brown gave the patient handover to the night staff RN White.
NUR3605 Sentinel Event For Nurse Assessment – Australia.
At 2130hrs Mandy complained of pain of 9/10 to RN White. According to the medication chart it appeared that no analgesia had been given since returning from theatre at 2010 hrs. So RN White along with endorsed EN Black gave 20mg Morphine IV at 2140.
It was a busy night with late admissions from theatre and ED and Mandy was not checked until EN Black went in to do post op observations at 2240 hrs. EN Black found patient A unresponsive, blue with a respiratory rate 4 and SpO2 76%.
A MET was called. problem identified was narcosis from morphine, when the progress notes were checked it was noted that Nurse Smith had documented that 20 mg IV morphine was given at 2055 hrs, but the medication chart was not signed.
NUR3605 Sentinel Event For Nurse Assessment – Australia.
the process NSQHS standards not followed include:
Standard 1 – governance to safety and quality systems
Standard 4 – medication safety
Standard 5 – comprehensive care
Standard 6 – Communicating for safety.
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