Introduction
Following Mr. B’s fall in the shower and subsequent shoulder injury, his death was an unexpected outcome. Shoulder injuries heal after relocation and rehabilitation and have no fatal outcomes. As such, it is probable that Mr. B’s death was caused by other factors that are remotely related to the fall’s injury. For this case, the main cause can be attributed to the sedation process.
Main causative factor: low oxygen levels in the brain
Upon reviewing Mr. B’s admission records, an issue of concern was his fall, had been caused by a black out. This led to further probing on the possible cause of his death. On the arrival of the patient, the nurse noted that his respiratory rate (R) was at 22 in comparison to normal levels of 60 – 100 BPM while heart rate (HR) while awake was 97 instead of the average 72 BPM. These are indicators that he had another problem, which caused the black out and the subsequent fall. The low R and high HR indicate that his brain cells were not getting sufficient oxygen. As such, the HR was very high since it tried to pump more oxygenated blood. This oxygen deficiency was the cause of the black out and the dying of brain cells, which indicates an internal problem.
Mixing valium with Dilaudid
The drug Valium was administered in combination to with Dilaudid. In total, the patient received 10 mg of Valium and 4 mg of Dilaudid. The maximum dosage is 10mg IV of Valium, which is what the patient received. However, it is considered a poor medical practice to mix with other drugs as it leads to precipitation (Shoestring graphics.com, 1997). In Mr. B’s case, this was mixed with a 4mg IV dose of Dilaudid, which could have caused the prolonged sedation given that Valium’s effect is short lived.
Low oxygen intake
One of the side effects of Valium is respiratory depression. Good practice requires that, upon administration of Valium, the Patient’s breathing be closely monitored for any side effects. However, this was not the case as the patient was only monitored for the blood pressure and the saturation of oxygen without monitoring the pulse rate and the breathing rhythm.
Slow response to low O2
Other than the Valium-Dilaudid combination, other factors might have contributed to Mr. B’s death. First, when Mr. B’s oxygen saturation alarm goes off indicating low saturation, the nurse in-charge resets it rather than acting on the information. At this point, the patient would have been put on supplemental oxygen, which might have prevented the need for resuscitation.
Understaffing
In addition, the hospital on this day was understaffed. With the nurse and the doctor attending to other incoming patients, the patient was left under the untrained care of his son who could not tell when the breathing stopped and only called for the nurse when the alarm went off again.
Late intervention
Though the hospital had enough equipment, the attending staff failed to use it appropriately to administer supplemental oxygen. The efforts to administer it were late which aggravated the situation.
Overburdened nurse
Moreover, the nurse was overburdened by the work and could easily fail to notice some signs of distress on the patient due to the work overload. Such signs when unnoticed could have led to the prolonged sedation and low O2 levels, which are bad for the brain cells’ health.
Improper response to the O2 alarm
In addition to this, the resetting of the O2 saturation alarm meant that the patient went without enough oxygen for long. This led to death of many cells, and by the time, supplemental oxygen was administered, they were already dead. With a large number of dead brain cells, the resuscitative efforts were futile as they only helped in breathing.
Administration of excess sedatives
Moreover, the fact that the patients had been using narcotics prevented the sedatives from working fast enough. The nurse and the doctor should have waited for more than 10 minutes before administering an additional dose. The initial dose might have succeeded in sedating and relaxing the muscles after some time thus preventing more sedation.
Old age and hypertension
Moreover, the age of the patient has to come to play in handling sedatives such as Valium as it is a strong drug. The medical staff could have used weaker sedatives given that the old man already has a history of hypertension and is taking painkillers.
Reference
Shoestring graphics.com. (1997). Quick Drug Reference. Web.