Scenario
You just received report on your client Sarah Jones who is in the Pre-Op unit. Per the shift report provided at the nurse’s station, Ms. Jones is scheduled to have a total right knee replacement. The reporting nurse states that the informed consent has been completed and is on file. The MD has ordered for Ms. Jones to receive Fentanyl for pain management prior to the procedure.
After reviewing the orders for Ms. Jones, you gather your supplies and medication and head into Sarah’s room. When you scan her arm bracelet and ask her to verify her name and date of birth, she states her name is Susan Jones. You ask her to state her name again and she says Susan Jones. You then remove her arm band and come back to the room with the new arm band.
Flustered, you scan the new arm band and Susan Jones shows up in the EHR. You scan the medication and see that Susan Jones has an allergic reaction to Fentanyl (Anaphylaxis). At the same time, you hear on the overhead pager for the charge nurse to report to OR #9.
Later at the charge nurse desk you discover that the patient Sarah Jones had her right lung removed, the surgery that in fact was supposed to occur for Susan Jones.
Post and Respond
1. Create an initial post that addresses the following in a maximum of 3 paragraphs total:
A. List the safety issues that you recognize in this scenario that could have prevented this sentinel event.
B. Discuss the components and significance of the Time Out in this scenario.
C. Had you not been informed of the incorrect procedure being completed on Sarah Jones, would you have reported the near miss event pertaining to administering a medication to the wrong patient? Why or why not?
2. By 11:59 pm (EST) Friday, respond to one classmate’s post. Your response could:
A. Expand on answering their questions.
B. Identify a different approach or insight.
C. Expand on their concepts or ideas.
3. Identify evidence-based practice in scholarly sources to support your posts. Provide your references in APA Style format.
Please note : Discussion post should not only answer the discussion prompt but should include a reflection and expansion of original EBP ideas. I will be looking for more application of concepts.
