Nursing Clinical Case Study Analysis

Whiley Drymon

Joann Ragan

Youngstown State University

CRN: 40989

11/23/2021
 Josie’s Story

Josie’s story was so close to my heart. One of my greatest fears is seeing my son die, I

can’t imagine living through anything worse honestly. It’s just gut wrenching to contemplate,

especially when caused by careless mistakes made by clinical staff. I know I would have been

much more demanding in my son’s care, but I have medical knowledge that many families do

not. I can only hope to have the strength Josie’s mother has, reliving the experience to teach and

prevent it from happening again.

There really were multiple mistakes during Josie’s care once she was transferred to the

intermediate care unit, many of which were completely careless. The nurses were not only

dismissive of the mother during patient care, but none of them were a patient advocate. With the

mother’s concern about hydration, wouldn’t that raise enough of a red flag to check the patient’s

chart for a recent I/O calculation? A patient or a caregiver has the right to speak to the caring

physician no matter what situation the patient is in.

The fatal mistake of a medication error by the final nurse is a terrifying but real danger.

No matter what the nurse was feeling, fatigue or burnout, she missed so many rights of

medication steps, failed to assess a patients need for a narcotic, and dismissed the legal guardian

of the patient who declined the medicine before administration.

Specifically speaking about the electronic medication record (EMR), the metanalysis of

over 47 studies have showed that organizations which implemented electronic health records had

a 30% higher guideline adherence, a reduction in medication errors by 54%, and a reduction in

adverse drug reactions by 36%. At least in Mercy health, you would have to be deliberate to

make this error by passing so many popup windows in the EMR to make a medication error on a

medicine the hasn’t even been order by the caring provided. (Alotaibi, 2017)
 Linda’s Story

This story deals with an anesthesiologist and an incorrect route given with a local

anesthetic. Linda came in for an ankle replacement and almost died because of a simple mistake.

When the injection was administered too deep, below the subcutaneous layer and into a vessel.

She immediately had a grand mal seizure followed by cardiac arrest. She was saved only with a

complete heart bypass and intubation.

So, a patient in fact went into a planned procedure not expecting much more than a nerve

block and had to fight for her life. These mistakes happen but are usually prevented when doing

the correct administration methods and following safety guides beforehand. The real mistake in

this case came after, in the patients care and follow-up. Hospital administrators and other clinical

staff discouraged the anesthesiologist from accepting blame with the patient and resolving the

mistake in a respectful manner, which Linda deserved.

This will impact me by carefully checking and then rechecking my medication rights to

avoid incorrect medication routes. Another impact will be my responsiveness on accepting my

blame when I make a genuine mistake. Accepting blame only helps to fix and issue, but more

importantly helping me learn and prevent a reoccurrence. We must be responsible for the care we

provide and have enough pride in it to defend, but that also means taking the responsibility to

correct actions for patient safety.

According to the British Journal of Anesthesia (Wahr, 2017), most medication errors that

happen in the operating room are preventable by almost 80 percent. Most of these are minor and

caught before causing any patient harm, but enough make it through each year that are fatal

mistakes, like it almost was for Linda.

 Noah’s Story

Just like Josie’s story, Noah’s was very personal to me. A parent shouldn’t have to say a

final goodbye to their son. It’s insult to injury with this family because they trusted the

healthcare system and the professional processes of clinical staff to take proper care of their son.

These mistakes were mainly communication based. Studies show the positive impact on quality

of care received from caring providers and clinical staff, which in turn contributes to patient

satisfaction. Patients are also more pleased and confident in treatment methods when they have a

voice in their care or a feeling of control in their own health care decisions. (Bombard, 2018)

Another major component I see is no one’s willingness to accept responsibility of care for

Noah. No proper assessments and follow-up by physicians after his initial procedure could have

killed him from either hemorrhaging or dehydration. Noah’s mother called the ENT service

multiple times but was quickly dismissed. An important note, when asked about blood in the

vomit, it was not explained how coffee-ground emesis means blood. Thankfully she brought him

into the ER, yet he was still passed around without a physician assessment, ushered out with a

quick and improper discharge.

The mother speaks true, stating of course she would have done things differently, but it

was not her job or responsibility to know his clinical aspects for him to receive proper care and

attention. Every person not only dismissed the mother but did not investigate his worsening

condition and advocate for their patient. Communication is so important, from patient to provider

and clinical staff to clinical staff. Using layman’s terms could have saved Noah’s life from the

start, catching his hemorrhaging both before and during his ER visit. People trust us with their

lives, and we must always take that seriously.

 References

Alotaibi, Y. K., & Federico, F. (2017). The impact of health information technology on patient
safety. Saudi medical journal, 38(12), 1173.

Bombard, Y., Baker, G. R., Orlando, E., Fancott, C., Bhatia, P., Casalino, S., ... & Pomey, M. P.
(2018). Engaging patients to improve quality of care: a systematic r
eview. Implementation Science, 13(1), 1-22.

“Josie's Story: Ihi - Institute for Healthcare Improvement.” IHI,

http://www.ihi.org/education/IHIOpenSchool/resources/Pages/AudioandVideo/
JosiesStory.aspx.

“Noah's Story: Are You Listening?: Ihi - Institute for Healthcare Improvement.” IHI,
http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/
NoahsStoryAreYouListening.aspx.

“The Patient and the Anesthesiologist: Ihi - Institute for Healthcare Improvement.” IHI,
http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/PatientandAnest
hesiologistPartThree.aspx

Wahr, J. A., Abernathy III, J. H., Lazarra, E. H., Keebler, J. R., Wall, M. H., Lynch, I., ... &
Cooper, R. L. (2017). Medication safety in the operating room: literature and expert-
based recommendations. BJA: British Journal of Anaesthesia, 118(1), 32-43.