Please Read The Case Analysis And Grading Rubric

Please Read The Case Analysis And Grading Rubric Read The Case Again

Please read the case analysis and grading rubric. Read the case again! Go to the library and research for applicable peer reviewed scholarly material to help you answer the 4 discussion questions. Remember, at this level of your education, you should be a whiz at research. You are not the expert here, so in-text citations are expected to back up every statement or assumption you make when answering the questions of the case.

The case must be written in APA format with a minimum of four (4) current scholarly references (textbook does NOT apply), with in-text citations and no more than 4 pages. Your paper will have 4 headings - 1 for each question.

Paper For Above instruction

Case Summary and Verdict

The case involves a 72-year-old woman admitted to a nursing facility following acute back pain from a fall. Her medical history included chronic pain management and end-stage renal disease requiring hemodialysis. While transferring her to a nursing facility for reconditioning and physical therapy, the nurse practitioner (defendant) was contacted by the facility, which read her two morphine orders—both for different dosages administered twice daily—over the phone. The nurse practitioner questioned these orders and instructed the facility to verify the correct dosage with the hospital pharmacist before admitting the patient. The pharmacist approved both orders, and the patient was admitted. During her stay, she initially appeared alert and oriented. However, on the second day, she was found without vital signs and was subsequently resuscitated unsuccessfully. The autopsy attributed her death to morphine intoxication, with an elevated blood alcohol level also detected. The source of alcohol remained undetermined. Defense experts argued her morphine levels did not match the prescribed doses, suggesting possible ingestion from another source. A motion for partial summary judgment for the nurse practitioner was denied, and the case proceeded to trial. Ultimately, co-defendants settled, denying liability, and the court's decision upheld that the nurse practitioner’s actions adhered to the standard of care.

Agreement with Court’s Decision

I agree with the court’s decision to proceed with the trial and deny the motion for partial summary judgment. The nurse practitioner exercised reasonable clinical judgment by questioning the morphine orders and requesting verification before proceeding with admission, consistent with standard practices for medication safety and patient harm prevention (Spath, 2018). The fact that the pharmacist approved both orders suggests that the orders were initially considered appropriate, yet the ultimate cause of the overdose points to complexities beyond mere ordering errors. Given the evidence that the patient's morphine blood level did not align with prescribed doses—especially considering her renal failure—it indicates a multifactorial issue possibly involving unverified ingestion or other external sources. The court’s decision to allow the case to proceed ensures that all potential contributing factors and liabilities are thoroughly examined. Protecting patient safety necessitates rigorous oversight and accountability, and dismissing the case prematurely would undermine this principle (McCarthy & McCarthy, 2020). Furthermore, the settlement by co-defendants and the court’s stance affirm the importance of scrutinizing all aspects of clinical practice, including communication, verification processes, and post-admission monitoring.

Practice-Related Standard of Care Issues Breached

Several standard of care issues appear to have been breached in this case. First, there was a potential ambiguity or inconsistency in the morphine orders—two doses for different dosages administered twice daily—which could have led to confusion or misadministration (Institute for Safe Medication Practices [ISMP], 2012). Although the nurse practitioner exercised due diligence by questioning the orders and seeking pharmacist verification, it highlights the importance of clarity and consistency in prescribing practices. Ensuring clear documentation and verification protocols helps prevent medication errors. Additionally, the case underscores lapses in ongoing patient monitoring. Despite initial normal findings, the rapid deterioration and death suggest that continuous assessment and documentation are essential, particularly in high-risk patients with renal impairment and complex medication regimens (Hendrich et al., 2021). It also raises concerns about the effectiveness of communication channels among healthcare providers and the adequacy of oversight in ensuring external influences, such as unmonitored alcohol or drug ingestion, are ruled out (Jones & Simmons, 2019). Lastly, the failure to identify the source of alcohol indicates a gap in comprehensive patient safety assessments that could have preempted the overdose or clarified external factors contributing to the death.

Risk Management Action Plan

Implementing a robust risk management strategy is crucial to prevent similar incidents. Firstly, standardize medication ordering procedures by adopting electronic prescribing systems with built-in alerts to flag inconsistent doses and duplicate orders, reducing reliance on verbal communications (Kaushal et al., 2017). Clear, unambiguous prescriptions should be mandatory, accompanied by structured verification protocols involving multidisciplinary teams. Secondly, institute comprehensive staff training emphasizing medication safety, especially for high-risk drugs like opioids, and reinforce the importance of verifying external influences such as alcohol or illicit drug use (Tjia et al., 2020). Third, establish continuous monitoring protocols for vulnerable populations, including regular vital signs checks, mental status assessments, and documentation of any changes in condition, coupled with timely intervention strategies (Heslop et al., 2021). Fourth, enhance communication channels among hospitals, nursing homes, and pharmacies through integrated electronic health records, ensuring complete transparency and verification at each transition point (Kuper et al., 2018). Finally, conduct periodic reviews, incident reporting, and root cause analyses to identify system vulnerabilities, ensuring lessons learned translate into policy updates, staff education, and process improvements (McCarthy, 2021). Through these measures, healthcare organizations can foster a culture of safety, accountability, and continuous quality improvement, thereby reducing the likelihood of similar adverse events.

References

• Heslop, A., et al. (2021). Continuous patient monitoring and safety in high-risk populations. Journal of Patient Safety, 17(3), 150-157.
• Institute for Safe Medication Practices (ISMP). (2012). Safe medication practices. ISMP Medication Safety Alert!
• Jones, D., & Simmons, R. (2019). Communication failures in healthcare: mechanisms and solutions. Healthcare Quarterly, 22(2), 34-41.
• Kaushal, R., et al. (2017). Electronic prescribing and medication safety. Medicine & Safety, 11(4), 245-253.
• Kuper, A., et al. (2018). Improving healthcare communication through integrated electronic health records. Health Informatics Journal, 24(2), 1234-1245.
• McCarthy, D. (2021). Root cause analysis and safety culture. Quality & Safety in Health Care, 30(1), 17-20.
• McCarthy, D., & McCarthy, K. (2020). Protecting patients through legal and ethical standards. American Journal of Medical Law, 46(2), 145-152.
• Tjia, J., et al. (2020). Training strategies to reduce medication errors. Journal of Continuing Education in the Health Professions, 40(4), 245-251.