* Mr. B presents to the Emergency Room with complaints of Left hip and leg pain * His son is at the bedside * Dr. T assesses Mr. B determining that he needs to set Mr. B’s hip at the bedside. * Dr. T orders moderate sedation * Mr. B takes oxycodone for chronic pain * Nurse J is assigned to care for Mr. B * Nurse J administers medications per Dr.T’s orders * 5 mg of Diazepam * Dr. T assesses Mr. B’s sedation level. Mr. B needs more sedation * Dr. T orders additional sedation medication * 2mg of Hydromorphone * Nurse J administers additional sedation medication per Dr. T orders * Mr. B B weight on admission was 175 pounds. * He was on a chronic pain regimen to manage his back pain. It included taking oxycodone routinely. * Chronic pain management made Mr. B difficult to sedate because he was not opiate naïve. * Individual Staff involved: * Dr. T failed to follow the moderate sedation protocol for acceptable dose ranges of medication. Dr. T failed to assess Mr. B post procedure. * Nurse J had to respond to new emergent patient in respiratory distress and became busy providing care to that patient * LPN disabled the oxygen alarm and failed to report her findings to Nurse J or Dr. T * Work Environment: * Emergency room located in a rural hospital * Adequate staffing with available staff not called in * Alarms were not responded to – not heard by all staff * Team Factors: * Protocol not followed * Poor communication between Nurse J and LPN
Casual Statements
The protocol for moderate sedation was not followed. Failure to follow the
protocol increased the likelihood of mistakes to be made. The mistakes included
improper medication dosing and inadequate monitoring of the patient post
procedure. These mistakes increased the risk that Mr. B would develop
respiratory failure and /or cardiac compromise. These mistakes led to the
profound hypoxic state, code blue, loss of oxygen to Mr. B’s brain
