The adverse event deals with a 67-year-old woman with diabetes and high blood pressure admitted to a hospital for hypertensive crisis treatment. The medication prescribed was to be used intravenously to reduce blood pressure. However, the nurse on a shift made an error and administered medication for increasing blood pressure meant for another patient with hypotonic crisis. The equipment used for pressure control at the hospital failed to register the drastic increase in blood pressure of a 67-year-old patient who developed myocardial infarction in a short time and had to be taken to the intensive care unit (Cantone et al., 2021). At the time of the event the cardiological department was highly understaffed with one nurse taking care of all the patients in the department. To determine the causes of the adverse event a fishbone diagram was used (Picture 1.).
From the perspective of the organizational management, the hospital failed to employ the necessary number of nurses which resulted in serious overload and burnout its staff experienced. Moreover, the investigation showed that patients’ names were not put on the medication and with so many patients to serve it was easy to make a mistake. However, the fault of the nurse in charge cannot be denied since she did not double check the medication which can be regarded as a case of carelessness. The failure of the equipment to register the increase in the patient’s blood pressure aggravated the situation leading to the loss of time when urgent measures had to be taken to correct the situation. Indeed, as Szabo puts it, the complete reliance on medical equipment in cardiovascular department can “lead to a serious health problem” (2019, para. 7). The resulted myocardial infarction can be seen as a combination of the above-named factors with the high blood pressure the patient initially had.
References
Szabo, L. (2019). Artificial Intelligence Is Rushing into Patient Care—And Could Raise Risks. Kaiser Health News.
Cantone, M., Lanza, G., Puglisi, V., Vinciguerra, L., Mandelli, J., Fisicaro, F. & Bramanti, A. (2021). Hypertensive crisis in acute cerebrovascular diseases presenting at the emergency department: a narrative review.Brain Sciences, 11(1), 70.