Situation Working Intensive Explained for Students (Easy Guide)

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Original Question

Situation: •An RN working in an intensive care unit faces allegations of failure to monitor, failure to utilize the nursing chain of command, and medication error. Background: •A 23-year-old woman with no significant medical history presented to the emergency room with flu-like symptoms. She complained of generalized body ache and had a fever of 102.6. For the past two weeks, she self-administered over-the-counter medications with no relief. Instead, her condition deteriorated and she developed both shortness of breath and a cough. Her worsening symptoms motivated her to seek care a local emergency room. Assessment: •Following an abnormal CT Scan of the chest (near-complete collapse of right upper lobe, large consolidation of the right lower lobe, and moderate consolidation of the left lower lobe of the lungs), an elevated white blood count (19,500), abnormal liver function tests and an abnormal coagulation profile, the emergency department physician admitted the patient to the intensive care unit under the care of an attending physician. The patient was started on oxygen and antibiotic therapy. Blood cultures were drawn and showed Streptococcus Pneumoniae and antibiotics were appropriately adjusted per recommendation of the infectious disease specialist. •The attending physician first saw the patient in the intensive care unit. At the time of his initial exam, the patient was not in significant respiratory distress, was responding well to the oxygen and antibiotic therapy, and was subsequently continued on the same therapy. The attending physician noted that while the patient was not in acute distress, her blood chemistry was abnormal with a potassium level of 2.9 (normal range is 3.5 to 5.0). The physician ordered 30mEq of potassium to be added to each bag of the patient’s intravenous fluid, infused at 80 milliliters per hour. The order was to be maintained through the remainder of her course of treatment. •Two days later and despite the potassium added to her intravenous fluids, the patient’s potassium level was noted to be 3.0 and the attending physician ordered 80 mEq of potassium to be administered by mouth. The patient vomited the medication (amount retained undetermined). The attending physician then ordered two doses of 40 mEq of intravenous potassium to infuse over a four hour time period with the plan of increasing the potassium level between 4 and 4.5. Documentation is problematic. It appears that despite the order for two doses of potassium 40 mEq to be infused over four hours, the intensive care unit nurse administered two intravenous potassium doses of 20 mEq over approximately one hour (documentation regarding this is inconclusive). •Throughout the day the intensive care unit nurse documented the patient’s heart rate in the patient care record. At 7:30 a.m. it was 72 beats per minute, at 1:30 p.m. it was 96 beats per minute and at 4:30 p.m. it was 116 beats per minute. The patient’s blood pressure remained stable at 120/80. The intensive care unit nurse did not specifically notify the physician of the pattern of rising heart rate. When the physician saw the patient that day, he noted that the patient’s white blood cell and platelet counts remained higher than normal but were dropping. In addition, her vital signs were within normal range and she was not in respiratory distress. He ordered a pulmonary consult for possible bronchoscopy but deemed that she was stable, and that vasopressors and aggressive pulmonary treatment were not necessary at that time. He ordered the patient to be transferred to the telemetry unit. •The intensive care nurse’s documentation fails to provide the exact time of transfer from the intensive care unit to the telemetry unit although it appears to have been between 7:15 p.m. and 7:30 p.m. The documentation also fails to validate the intensive care nurse’s statement that the patient was on a cardiac monitor during her intensive care stay and that she was transferred to the telemetry unit with a cardiac monitor and oxygen therapy. The telemetry unit nurse stated the patient did not arrive with a monitor. Other telemetry unit staff indicated that the telemetry unit was in an overflow situation when the patient was transferred and the central monitoring station was not functioning. Regardless of the actual reason, there are no telemetry unit electrocardiogram strips for this patient. According to hospital records, the attending physician was called at approximately 10:00 p.m. and was advised that the patient had gone into cardiac arrest. The on-call emergency physician attempted to resuscitate, but was unable to obtain a heartbeat and the patient was pronounced dead. Outcome: •The family of the deceased sued the attending physician, the hospital and three of the hospital’s registered nurses, and sought $3,000,000 in damages. The allegations against the intensive care unit nurse included alleged failure to properly administer the medications as ordered by the physician and failure to notify the attending physician of significant changes in the patient’s vital signs and laboratory results. Respond to the following questions–apply the nursing process as applicable: 1.) What did the RN fail to notify the physician of? 2.) What should the ICU RN have done prior to transferring the patient to the telemetry unit? What considerations should be taken into account when physically transferring the patient from the ICU to the telemetry unit? 3.) If the RN did not feel comfortable with her assignment, what could she have done? 4.) What was missing from the ICU RN to telemetry RN’s handoff report? 5.) How does documentation play into this case? 6.) What recommendations do you have for the ICU RN to prevent this situation from happening again in the future? Case Study Resolution: After the expert witness stated the intensive care unit nurse’s care and treatment of the patient was not medically defensible, the claim against her settled at mediation for $100,000 with an additional $6,152 in legal expenses. The total settlement amongst all of the defendants in the case was $1.4 million.

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