Slide Presentation of the 2007 Annual Meeting of AHRQ

Case Study 1 (cont.)

That morning the nurse made a series of errors that resulted in the death of a patient
1) she failed to place the armband on the patient's wrist
2) at 11:30 pm she removed the patient's medications from the pxyis along with the epidural medications (a combination of bupivacaine and fentanyl) that she
thought might be needed later and placed them on a counter in the birthing room
3) after starting an IV on her patient at 12:06, grabbed the bag of what she thought was penicillin and added it to the IV without checking the bag, scanning the
patients wristband or using the bar-code administration system