NR544 Week 4 – Risk Management and Patient Safety
Scholarly Discussion Forum, Case Scenario, and Answer Preview
Overview
Risk management is a cornerstone of patient safety in nursing practice. In Week 4 of NR544, we examine a real-life nursing home case that illustrates how medication reconciliation errors, communication breakdowns, and system gaps can lead to adverse patient outcomes.
This discussion forum aligns with the Quality and Safety Education for Nurses (QSEN) competencies and current Joint Commission safety goals, making it highly relevant for nursing students preparing for advanced practice roles.
Learning Objectives
By engaging with this case scenario, you will be able to:
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Recognize high-risk transitions of care and their impact on patient safety.
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Apply evidence-based risk management strategies to clinical practice.
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Develop an action plan based on a recognized patient safety theory or model.
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Understand the role of clear, structured communication in preventing errors.
Case Scenario
Risk Management and Patient Safety. Diane was an 80-year-old resident who was returning to the nursing home from the hospital following a left hip fracture on Friday evening. She has a history of congestive heart failure with frequent exacerbations. Her hospital discharge medication list was different than the prior medication list at the nursing home, specifically relating to her Lasix prescription. Diane was already taking Lasix at the nursing home before her hip fracture. All of her medication orders were transcribed by hand onto a new medication administration record (MAR). The old MAR, prior to the hospital stay, was not removed. The nurse checked Diane’s new orders and wrote “repeat” next to the new Lasix order and yellowed out the line. She was interrupted and was not able to finish reviewing the orders so she asked another nurse to review it for her. The second nurse reviewed the order and saw that the old MAR was still there. She removed the old MAR and finished reviewing the new MAR.
On Sunday, the medication nurse passed meds for Diane, as she had done for the past three days. She saw the yellowed line through the Lasix order and thought that the medication had been discontinued. She sent the medication back to pharmacy. Pharmacy picked up the medication on Monday. On Monday, it was noted that Diane weighed three pounds more since being discharged from the hospital. The nurse recorded the weight and placed a call to the physician, who failed to respond. At 2:00 a.m. Tuesday morning, Diane began to have difficulty breathing. Assessment findings included +4 pitting edema, a BP of 190/110, a HR of 120, and respirations at 28. Crackles were heard through her lungs. The on-call physician was consulted and an order was placed to transfer Diane back to the hospital. She went into cardiac arrest while waiting for the ambulance and was not able to be resuscitated.
Discussion Prompt
Provide your risk analysis for this event. Develop an action plan for the prevention of events like this one in the future. Which theory or model would you apply in developing your action plan?
Snippet of Answer
There are many risks involved in this case scenario. The first risk identified is that the differences in her medication list. This difference is specifically noted in her Lasix prescription. Another risk identified is the presence of two MARs, the new and the old one. The old one was not removed and not be a source of confusion when prescribing medications to this patient. The third risk is the lack of communication between nurses. The first nurse could not complete the patients’ medication review and asked another nurse to complete it without explaining to her what she had found out so far. The nurse could have informed the one she delegated the task to about the old MAR and the repeat medication. Also, the nurse assigned did not take time to check the old MAR but just removed it. She did not communicate with the medication nurse who passing medication to the patient
Get the Full Solution
The complete answer includes:
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A detailed root cause analysis of the event.
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A comprehensive prevention plan aligned with QSEN and AHRQ best practices.
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Application of the Swiss Cheese Model with academic references.
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