Aim:
This task requires you to demonstrate your understanding and ability to apply key concepts presented in modules 1 and 2 and relate these to the legal, ethical and socio-political concepts that you are able to identify in one of the two case studies supplied.
NUR241 Case Study Analysis Assessment – Australia.

Task description:
This task is based on two medication case studies. You can access the case studies below.

Case study 1:
Janet Ann Cook, 79, was admitted to a South Australian hospital on 25 March 2020 for end-stage cardiac failure, complicating liver and renal failure.

She was placed in room 26 – however, just two doors away in room 28 was a lady by the name of Norma Cock.

Mrs Cock was a patient who required both subcutaneous Novo rapid 52 units mane, a drug kept in the fridge in the medication room, and 12 units Lantus subcutaneously mane.

Meanwhile Mrs Cook was prescribed Metformin 500 mg BD and Actrapid as per sliding scale chart.

There were two nurses present at the bedside when Mrs Cook was mistakenly administered Novorapid 32 units and Lantus 12 units subcutaneously, after which she died nine days later.

One of them was an enrolled nurse primarily responsible for the care of both Mrs Cook and Mrs Cock, as well as two other patients in the ward.

This nurse, who has since been the subject of an inquiry by AHPRA, was adamant that a registered nurse who had accompanied him had administered the medication to Mrs Cook without calling out the identity numbers first.

NUR241 Case Study Analysis Assessment – Australia.

He also claimed that he did not see the medication being given because he was busy looking at the patient chart.

“It is apparent also that he observed the medication being administered to Mrs Cook who, had he been concentrating, he would have identified as the wrong patient, having nursed both Mrs Cook and Mrs Cock that morning.”

“It is consistent with that state of inattention that he would also have failed to listen carefully to the identification as read out from the wristband.”

“That, in summary, is the coroner’s findings as to the explanation for the medication error in this instance.”

An expert witness told the inquiry that the medication error “materially shortened” Mrs Cook’s life expectancy and that the dose of insulin would have “flattened her”—as she was a frail elderly patient who had liver impairment.

“It is no coincidence that her health dramatically deteriorated in the hours following the administration of the insulin,” the coroner found.

Case study 2
The South Australian Health Practitioners Tribunal has suspended former Flinders Medical Centre (FMC) emergency department clinical nurse.

Ms New black, a registered nurse with a previously unblemished record in 23 years of work, had been dealing with a family crisis and agreed to look after the patients of another nurse, who was going on a tea break.

One of her new tasks was to administer morphine to the patient, referred to as “BZ”, in cubicle 33. The drug was handed to Ms Newblack in a kidney dish.

Ms Newblack went alone into cubicle 36 and not cubicle 33. She went into the cubicle alone and administered the morphine to the patient as directed by the nurse going on break.

When the other nurse returned from her tea break, she realised Ms New black was in the process of administering the drug to the wrong person.

Ms New black inveigled the registered nurse and the enrolled nurse on duty at the time not to report the incident.

“Initially, the enrolled nurse agreed to do this but then thought better of it and notified her supervisors which led to the Flinders Medical Centre carrying out their internal investigation.”

Patient BZ was never told of the morphine mix-up.

Ms Newblack was registered as a nurse in 1995 and started working at SA Health in the Repatriation General Hospital in the acute referral unit before moving to the FMC emergency department as a clinical nurse.

The tribunal noted that Ms New black had a previous unblemished record, felt “deeply remorseful for the choices she made” and since the incident, had engaged in extensive education.

NUR241 Case Study Analysis Assessment – Australia.

You are required to examine the key legal, ethical and socio-political aspects of one of the case studies, taking into account the scope of practice of the registered nurse and consideration of safety and quality in medication management practices via national standards.