1

Make Up Clinical Case Study Assignment:

Josie’s Story, The Patient and the Anesthesiologist, and Noah’s Story

Alissa L Sipus

Department of Nursing, Youngstown State University

NURS 3741L: Professional Nursing II Lab

JoAnn Ragan-Kyser

November 26, 2021

Josie’s Story

After watching and listening to Josie’s story, it has impacted the way I will provide care

for my patients as a nurse. I will be sure to go over the five rights for the mediation, I will also do

my three medication checks, and my two patient identifiers. I will for sure utilize epic because

with epic you scan the patient wrist band and the medication, if it’s not ordered for them, it will

alert you. I will also listen to the family because they know the patient and they know when

something may not be right, I will not believe that I am above them questioning me to protect

their loved one. I don’t think it is ever a bad thing to ask question or want an explanation on why

a procedure, medication or anything is being done, they have the right to know.

If this were to happen to a loved one, I don’t think that I would respond as well as Josie’s

family did. They decided to share their story to try and prevent this from happening to others. I

think that I would want answers, for me to understand things I need explanations. I would want

to know why the nurse gave the medication when it wasn’t supposed to be given and what were

her intentions. I would probably blame myself too because I would wonder if there was

something I should have said or did that could have stopped this kind of event from occurring. I

would be angry for a while, but hopefully I would get closure and to try to prevent it from

happening to anyone else.

The peer reviewed article that I found was Medication errors in emergency departments:

is the electronic medical record an effective barrier. This article showed the comparison of two
3

emergency departments, one if which used the electronic medical record and the other used the

conventional handwritten record both were a part of the same organization and this study

occurred over one year. They used cross-sectional, retrospective, and observational study for

comparing the two departments. The results showed that the emergency department that used the

electronic medical record had almost half the amount of medication errors as the departments

that used the conventional handwritten record and it contributed to improvement of the patient’s

safety (Vaidotas et al., 2019).

The Patient and the Anesthesiologist

A sentinel event is an unexpected occurrence involving death or serious physical or

psychological injury, or the risk therefor. Giving or administering medication the wrong way can

cause a sentinel event. In the case study, The Patient and the Anesthesiologist a sentinel event

did occur. When a medication is provided the wrong route, it can cause serve complication and

problems for the patient. Specifically in the case the anesthesia was not supposed to enter the

blood circulation, but it did which caused cardiac arrest and ultimately lead to the patient flat

lining. There are many other ways to provide a medication wrong from crushing a medication

you shouldn’t to giving a medication intravenously that shouldn’t be, these can and will cause

life threatening complications for the patient.

This story will impact my practice because I will be vigilant and aware of what route

medication is supposed to be given. I also will be aware of what adverse reactions could occur
4

when giving a medication the wrong route so then I can watch for it in my patients if a mistake

were the happen. I would also be honest on what error occurred and talk to who every handle

those situations. I personally would want to talk to the patient and explain what occurred and

apologize if there was something I did wrong of something I could have stopped. Listening to

this story will impact my practice as a RN.

The peer reviewed article that I found was ‘Never Events in Surgery’: Mere Error or an

Avoidable Disaster. This article talked about how ‘never events’ do occur in surgery, and how it

would be hard to find a surgeon who never had a mistake occur. It then reviewed the identified

some risk factors such as negligence, mediation error, wrong site, wrong procedure, wrong

patient. Those are just some of the ‘never events’ but there are many more that can occur. It then

talks about what can and does contribute to these errors and how we can minimize these events

from happening. Overall, the goal is to not have ‘never events’ because they are preventable, and

they can be avoided (Kumar & Raina, 2017).

Noah’s Story

Form reading about Noah’s story I learned that one thing that can happen from not

listening to patient family concerns is death of the patient. In his case they didn’t answer her

questions, listen to her concerns, or may attention to what she was telling them. When you don’t

actual stop and listen to the patient family concerns you can miss important information that

occurred with the patient that you could be crucial. You can end up harming the patient, not
5

catching important diagnosis and ultimately loose the patient. The nurse along with the everyone

apart of the care team need to listen and acknowledge when and if the patient’s family has

concerns.

Noah’s story will impact my nursing practice as a RN because this really shows you how

important it is to listen to the patient or in this case the patient’s family. It has also showed me

how important it is to educate the family on what to look for that indicates complications and

that starts with the discharge process. For example, in Noah’s case, he was throwing up blood,

but his mother didn’t know that coffee ground colored vomit indicates that. I would do my best

to educate the family on as much as possible but also, I would want to ask questions to learn as

much information on what’s occurring with the patient and get them the help if and when its

needed.

The peer reviewed article that I found was A Narrative Review of Patient and Family

Engagement: The “Foundation” of the Medical Home. This article was written to show how

patient and family engagement in pediatric and adult medicine improves quality of care and is

needed for optimal health outcomes. They did this by getting a panel of health care providers and

they met monthly to review evidence around patient and family engagement, they would conduct

preliminary literature searches to find articles related to PFE published between 2000 and 2015.

They found that working with patients and families has a lot of potential to support quality health

care and optimize outcomes (Cené et al., 2016).

Synopsis

Overall, throughout reading and listening to these case studies and reading through my

peer reviewed articles I learned a lot and it will impact the way I practice as an RN. From the

first case study I learned how important it is to utilize the EMR and you need to be doing your

two-patient identifier, three medications checks and the five rights for medication. From the

second case study I was able to see and learn how never events occur and what we can do to

make sure and prevent them from occurring not only in the OR but anywhere. Then from the last

case study I learned how important family and patient participation is because it can and will be

crucial for quality patient outcomes.

References

Cené, C., Johnson, B., Wells, N., Baker, B., Davis, R., & Turchi, R. (2016). A Narrative review

of patient and family engagement: The “foundation” of the medical home. Med Care,

54(7): 697–705. doi:10.1097/MLR.0000000000000548.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4907812/

Josie's story: Ihi - Institute for Healthcare Improvement. IHI. (n.d.). Retrieved November 23,

2021, from

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

JosiesStory.aspx.

Kumar, K., & Raina, R. (2017). ‘Never events in surgery’: Mere error or an avoidable disaster.

Indian J Surg, 79(3):238–244 doi:10.1007/s12262-017-1620-4

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5473801/pdf/12262_2017_Article_1620.

pdf

Noah's story: Are you listening?: Ihi - Institute for Healthcare Improvement. IHI. (n.d.).

Retrieved November 23, 2021, from

http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/

NoahsStoryAreYouListening.aspx.

The patient and the anesthesiologist: Ihi - Institute for Healthcare Improvement. IHI. (n.d.).

Retrieved November 23, 2021, from

http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/

PatientandAnesthesiologistPartThree.aspx.
8

Vaidotas M, Yokota PK, Negrini NM, Leiderman DB, Souza VP, Santos OF, & Wolosker N.

(2019). Medication errors in emergency departments: is electronic medical record an

effective barrier? einstein (São Paulo), 17(4): 1-5.

http://dx.doi.org/10.31744/einstein_journal/2019GS428