Annie - NurseAnnie - Nurse taking care of patient ...Initial AssessmentWhat 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 glucomenterPatient DecliningAssessment ReviewShare 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 bedPatient diaphoretic and unresponsive, rapid response calledNurse BlamedSummary: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 ClearedSummary: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 DebriefWhat can our team learn from this case to improve the care in a similar situation?Team Discussion (~5 min)Systems Discussionscenario feedbackWhat 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)Issues:- misleading information from equipment- lab response time- just culture for care giver
