RCA Discussion

CaseScenario2RCASummer2016.docx

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The patient was a 67-year-old male who underwent a right total knee replacement. Following the procedure, the patient was treated in the post-anesthesia care unit where an epidural catheter was inserted for postoperative pain

management. Following one episode of hypotension, which was treated successfully with ephedrine, the patient was discharged to an inpatient medical-surgical care nursing unit with the epidural in place.

Although the nurse assigned on the medical-surgical unit customarily worked on the postacute critical care unit, she had been reassigned to the medical-surgical nursing care unit. The nurse stated that she understood her assignment at the time of the patient’s admission to this unit was to provide oversight of the patient care on the entire floor for that shift. The nurse assessed the patient upon his admission to the unit and found him to be stable. The nurse understood that the direct care of the patient was assigned to a licensed practical nurse (LPN). Ordered vital signs and checks of the xyphoid process were not documented.

Approximately 3 hours after arriving on the unit, the patient was unable to tolerate ordered respiratory therapy due to nausea and vomited shortly thereafter. According to the nurse, approximately 10 minutes after the episode of vomiting, the LPN found the patient cyanotic and unresponsive and immediately called a code.

The nurse responded, as did the code team, and the patient was intubated and transferred to ICU. This account of events was disputed by the LPN and two other staff on the unit who understood that the nurse was responsible for the direct care of the patient. The LPN stated that it was the nurse who found the patient to be unresponsive at some point after the episode of vomiting and called the code herself. The elapsed time between the episode of vomiting and the code is also disputed.

The eventual diagnosis was anoxic encephalopathy due to the time that elapsed before CPR was initiated. The prognosis was poor and life support was withdrawn. The patient breathed independently and was transferred to hospice care where he subsequently expired.