Case Study: Failure to Monitor Post-surgical Patient
Read the case study at the end of chapter 11.
Instructions: After reading case study, please write a short paragraph depicting which were the most important failures that led to the near death event of the patient?
What did you think was the most important contributor of all?
A young man, Mr. Steve Goldberg, was admitted to a surgical unit at 6:00 PM after an elective laparoscopic gastric bypass surgical procedure. Mr. Goldberg was stable at the time of admission and was receiving a patient-controlled narcotic infusion at a “high-normal” range for pain management via a PCA pump. He was receiving oxygen via a nasal cannula at 2 liters per minute.
On admission to the surgical unit, Mr. Goldberg’s blood pressure was stable at 142/87. He stated that he was comfortable but at times appeared uncomfortable and restless. At 8:50 PM, the patient denied having pain and wanted his oxygen removed. His oxygen levels were adequate, and the respiratory therapist removed the oxygen cannula at that time but left it in the room per routine procedure. Mr. Goldberg continued to be restless throughout the evening and was observed repositioning himself in the bed for comfort.
At midnight, the nursing assistant, Ms. Veronica Martin, removed the blood pressure cuff from Mr. Goldberg’s arm for comfort after recording a blood pressure of 92/44. She did not inform the registered nurse, Ms. Margaret Bennington, of the decrease in blood pressure but recorded the blood pressure on her worksheet, a nonpermanent record on a clipboard that contained the vital signs of the patients assigned to her. The nursing assistants used the worksheet to record vital signs for the registered nurse’s review before documenting them in the permanent medical record.
At midnight, however, Nurse Bennington was busy admitting a new patient. One hour later (1:00 AM), Nursing Assistant Martin repeated the blood pressure measurement and documented a blood pressure of 76/34 on her worksheet. Again, Nursing Assistant Martin did not report the increasingly lowered blood pressure to Nurse Bennington.
Nurse Bennington stated that at 2:45 AM she checked on Mr. Goldberg and characterized him as being restless, able to hold a conversation, and complaining of being too hot. Nurse Bennington gave Mr. Goldberg a cool wet cloth and took his blanket off. Nurse Bennington did not check any additional vital signs or ask to see the recorded blood pressure readings, stating that she assumed the patient was stable.
One hour later (3:45 AM), Nursing Assistant Martin was assigned for a short time to another unit. She did not communicate any information to Nurse Bennington regarding Mr. Goldberg before leaving the unit. She returned approximately one and one-half hours later.
At 5:15 AM, Nursing Assistant Martin returned to the clinical unit and recorded Mr. Goldberg’s vital signs as 77/34, pulse 100, and respirations 20. Nursing Assistant Martin gave Nurse Bennington a brief report on a second patient and then left to take a third patient’s vital signs.
At 5:30 AM, the surgeon, Dr. Steel, came in earlier than his usual time to evaluate the patient. Dr. Steel’s intentions were to quickly assess the patient and then leave for the airport where he had an early commercial flight to catch. Dr. Steel stated that he could hear Mr. Goldberg snoring as he approached the room, and when he entered Mr. Goldberg’s room, he found the patient cyanotic from the neck up and unresponsive to verbal stimuli. Dr. Steel left the room to get Nurse Bennington for help, and together they returned to Mr. Goldberg’s room.
Nurse Bennington stated that Mr. Goldberg was positioned on his side, which was unusual, and that it was obvious he wasn’t doing well. His color was poor, respirations were slow, and he was unresponsive. At this time, Nurse Bennington repositioned Mr. Goldberg on his back to open his airway and improve his breathing.
Over the next 50 minutes, the narcotic infusion was discarded and Mr. Goldberg received two doses of medication to reverse the effects of the narcotic infusion. His arterial blood gases were assessed, and his oxygen was reinstituted via nasal cannula. He remained on the surgical unit for approximately 50 minutes while, according to each of the three staff members interviewed, Dr. Steel was reclined in a chair in the corner of the patient’s room or at the nurses’ station making phone calls while they suggested interventions to him.
The three registered nurses interviewed expressed concerns about their perceived delays in treatment after Mr. Goldberg was discovered in his unstable condition, and attributed the delays to waiting for Dr. Steel to take the initiative. According to Dr. Steel, he reinstituted Mr. Goldberg’s oxygen, instructed Nurse Bennington to turn off the patient-controlled narcotic infusion, and to give the medication to reverse the effects of the narcotic.
Dr. Steel left to catch his plane before the patient was stabilized. Mr. Goldberg showed some improvement before Dr. Steel left. Dr. Steel stated that he thought the patient’s systolic blood pressure was approximately 100, and he had oxygen saturation levels of approximately 92%. Neurologically, his pupils were reacting slightly; he was posturing on his left side and flaccid on the right side, and remained unresponsive to verbal stimuli.
Mr. Goldberg was transferred to the intensive care unit at 6:20 AM where the nurses in the ICU quickly increased the oxygen support and added intravenous vasopressors per protocol after consultation with the on-call physician in internal medicine, Dr. Asvall. A gap of approximately 30 minutes occurred between the time Dr. Steel left for the airport and the time Dr. Asvall arrived to manage the case.