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1. 

Read Case 9: "A Cascade of Small Events: Learning from an Unexpected Postsurgical Death "  in CASE STUDIES

Discuss what went wrong with Nick's care?  What remedies would you consider?


2.

Read Case 18 in CASE STUDIES:  Not for IV Use:  The story of an Enteral Tubing Misconnection.

Discuss Question 1.  What chain of events and mistakes led to the Death of Robin and Allison Lowe, Robin's baby?  At what point in the chain could the pending disaster have been stopped? What processes could be put in place to prevent such an event from occurring?

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