Case study:Miroslava Semenov Earlier Wednesday afternoon, at… Case study: Miroslava Semen

Case study:Miroslava Semenov Earlier Wednesday afternoon, at… Case study: Miroslava SemenovEarlier Wednesday afternoon, at Hillside General Hospital the Medical Examiner ruled the death of 9-month-old was an accident. The medical examiner said the death was the result of complications following administration of an adult dose of the antibiotic azithromycin, which is commercially known as Zithromax. Parents said their daughter became ill 10 days ago and has not improved, so they took her to the hospital where she was born.Nurse in ER stated that she noted some challenges with English language and asked for interpreter to be help with their communication. “She catch cold and we took her to the emergency,” mom said.Hospital records showed Mirsolava was brought to the ER “alert and responsive” and with the exception of a fever, which was reported to be around 39.4C. No other significant visible symptoms were noted on initial assessment.  On a further extensive examination, the infant was diagnosed with clinical pneumonia. Miroslava was prepared for transfer to the pediatric unit and given a dose of the azithromycin through an IV drip in her right arm.According to the nursing notes, at least 36 minutes passed before the hospital staff realized something was wrong.After the medical inquire a reporter asked the parents who they blames for their daughter’s death.They stated…”Hospital management, doctor, nurse—of emergency”.”I’m like ‘look, look my baby’s dying! My baby’s dying!’ and then nurse came over and said ‘no, you’re baby’s pretty good. She’s sleeping,'” Mother explained.A copy of the hospital’s discharge summary states the child was given “Azithromycin (500mg), in error” — which led to “cardiac shock.”Family pediatrician on duty in ER stated that dosage is more typical for an adult and not a 20-pound infant. “Nobody can feel worse for the family than the doctors and nurses that were involved in this child’s care,”. “About 80 milligrams would be appropriate for a child roughly in his weight class.”Less than 24 hours after the overdose, the parents were told their daughter was brain dead. The child was taken off a respirator and died after 24hrs post admission.”They told us there is no hope because his head is totally collapsed,” stated the father.The Hospital Administrator stated, “We are investigating the circumstances of this tragic incident and express our condolences to the family.””I never think like that she pass away forever,” Mother stated. “I thought she’s gonna come back.”Parents are both devastated and outraged over a fatal medical mistake that cut short their baby’s life just as it was getting started.After an error has occurred:1. List the possible mistakes that could have occurred in the case study2. How should the nurses respond in this situation.3. How should the medical team respond. 4. What are the steps nurses need to follow once they identified the errorCase study cont.At the time after the error was identified the nurse that had given the incorrect medication dosage stated to her co-worker. “We won’t tell the patient family”.  I am sure the child will be alright with the intensive care management”. Answer the following questions:5.   When and why are family member notified about errors?6. Identify what the appropriate documentation for medication error. 7. What are the possible consequences for the nurses involved.Prevention8. List the prevention strategies and the rationale (give 6 points). 9. List the measures the nurse keeps in mind to reduce the risk of MEs?10. What are the organizational factors contributing to errors?11. List the educational system issues and their potential impact on errors. 12. List the socioeconomical issues that contribute medication errors.  Health Science Science Nursing NURSING 2H03 Share QuestionEmailCopy link Comments (0)

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