MN 506 Case study. GroupC. Unit 7-3.docx

Risk management issues after the incident after the

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Risk Management Issues after the Incident After the incident, risk management was unable to retrieve accurate details that lead to the sentinel event. Again, the documentation in all events leading to the conclusion of Mrs. Carpenter’s death also lacked significant details to fully understand what truly occurred during this particular event. In this particular case Susan Post, JD, the risk manager also works with the quality assurance director Amy Green. Over the last three months, Amy had noted when doing chart reviews there were several incidents where vital signs taken in the recovery room were not charted. There was also noted a frequent pattern of using float nurses in several postoperative units. Prior to this incident, there was an ongoing assessment of the status of staff education and what type of resources and training was needed. Documentation and Mandatory Reporting The documentation that was available stated that upon admission, Mrs. Carpenter’s intravenous line, level of consciousness and pain were assessed. It appears that there was no head to toe assessment, no vital signs and no epidural site assessment documented. Approximately an hour after the patient was admitted to the unit, it was noted that the patient was unable to tolerate a respiratory therapy that was ordered and she became nauseated and vomited. The registered nurse, Kelly documented that 10 minutes after the vomiting episode, Joseph Alcoff, the LPN, found the patient blue and unresponsive and called a code. However there was conflict in testimony between Joseph the LPN and Kelly the RN. Joseph the LPN indicated that Kelly the RN found the patient to be unresponsive after the vomiting episode and called the code, however the time elapsed between the vomiting episode and finding the patient is in dispute.
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CASE STUDY II 7 Finally, vital signs were ordered by the physician to be obtained hourly however the documentation to correlate with the physician order did not occur. The hypotensive episode in the recovery room also had not been reported to the receiving registered nurse. There was an obvious disconnect between the hand off communication, documentation and proper education in the unfortunate case of Mrs. Carpenter. Due to the negligent care and lack of proper documentation and reporting Mrs. Carpenter lost her life after a very common surgery that most recover from rapidly with no complications. In the case of, Guzman-Ibarguen v. Sunrise Hosp. and Medical Center (2011), the patient was not properly monitored and also resulted in unsuccessful resuscitation and this sentinel event led to further investigation. Informed Consent The issue of informed consent remains a work in progress and leaves plenty of legal implications in its wake. Informed consent has been codified into law after the legal precedent was set in 1914 when a doctor removed a tumor from a patient who had only consented to a diagnostic procedure. The judge ruled that the patient’s fundamental right to decide what was to be done to her body was violated and the doctor was guilty of battery (Schoendorff v. Society of
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  • Spring '17
  • Dr Smith
  • Nursing, Medical malpractice, Registered nurse, Mr. Howard Carpenter

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