Word count 1600 +/- 10%
15 minimum high-quality resources (published within the last 5 years) – APA 7^th format follow Victoria, AUS curriculum

Case study

Mr Evans, a 45-year-old man presented to a small regional hospital Emergency Department with a laceration to his leg caused by an accident with farming equipment, and dehydration due to delays in calling for help. His laceration was cleaned and sutured, and he was rehydrated with IV fluids with good effect but he experienced some mild nausea. The doctor ordered 5mg of IV metoclopramide for nausea, and 1g of oral paracetamol for pain as a STAT dose before discharge.

The nurse on duty, Lorna, was a registered nurse with 40-years’ experience, and was the Assistant Director of Nursing at the hospital. However due to staff absences, she was helping in the ED for the shift. Lorna had not worked clinically for many years, but she wanted to support her staff.

She introduced herself to Mr Evans and he asked about having his medications because he wanted to go home as soon as possible. Lorna read the medication chart, but she felt unsure about administering the medications, so she consulted with experienced ED nurse, Barry, who said that he’d prepare the medications for her even though he was very busy. Barry read Mr Evan’s medication chart and prepared the IV metoclopramide and noting that the patient would possibly not tolerate tablets due to nausea, he drew up 1g of oral paracetamol elixir liquid into a syringe and put both syringes in a tray. He then gave the tray to Lorna and continued his shift.

Lorna noticed that both medications were in syringes, and she assumed both were for injection. She was unaware that paracetamol could be given via IV route so she asked a passing nurse (Kate), “can paracetamol be given IV? and Kate replied “yes”. Lorna proceeded to give both medications into Mr Evan’s IV cannula. Mr Evans immediately developed symptoms of a pulmonary embolus, which proceeded to a massive stroke, and he was declared deceased after 30 minutes of resuscitation attempts.

Scenario adapted from Staunton, P. and Chiarella, M., 2012. Law for nurses and midwives. Chatswood, N.S.W.: Elsevier Australia

Using the case study complete a root cause analysis, and respond to the following sections:

1. Description: provide a brief description of the event (the case study) and the outcome for the patient.
2. Identification of root cause and contributing factors: Identify one (1) root cause and discuss at least three (3) contributing factors which have likely caused this sentinel event.
3. Links to NMBA RN Standards for Practice: Identify and discuss at least two (2) NMBA RN Standards which were not practiced or maintained by the nurses involved in this sentinel event, that may have led to the identified root causes.
4. Links to National Safety and Quality Health Service (NSQHS) Standards: Identify and discuss at least two (2) NSQHS Standards which were breached (or not met) by this health organisation, that may have led to the identified root causes.
5. Recommendations: Outline a minimum of three (3) recommendations to address the root causes identified from the chosen case study. These recommendations need to include practical examples and identify who is responsible for actioning these recommendations. (using evidence-base resources for recommendations and practical examples)