Annie - Nurse
Annie - Nurse taking care of patient ...
Initial Assessment

What do you think is going on with this patient?
(everyone to answer)

Initial Assessment ( ~3 min)

Patient tells Annie that she felt like her blood sugar was high.

Another nurse uses the glucometer, and confirms with Annie that glucometer confirms that patient's sugar level was critically high.

... see image of glucomenter
Patient Declining
Assessment Review

Share what you are most concerned about.
(everyone to answer)

Assessment Review ( ~3 min)

Patient given insulin, and suddenly becomes unresponsive prior to getting back into bed

Patient diaphoretic and unresponsive, rapid response called
Nurse Blamed

Patient transferred to ICU, found to be severely hypoglycemic.

Records indicated Annie requested Insulin several times from doctor.

Annie disciplined for improperly diagnosing patient.
Annie Cleared

Another nurse on another patient had a similar event.

Human factors called in to review, and determined there was a equipment issue.

Annie's discipline removed.
Team Debrief
What can our team learn from this case to improve the care in a similar situation?
Team Discussion (~5 min)
Systems Discussion
What systems do we have in place to prevent this?
(every team member to answer)
What system issues might have contributed to this outcome?
(every team member to answer)
Systems Discussion (~5 min)
- misleading information from equipment
- lab response time
- just culture for care giver
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