Event Investigation and Analysis Guide: Appendix B

Detailed Review Timeline

Event Type:

Individuals Interviewed:

NAME TITLE/ROLE
Nurse #1 Charge nurse
Nurse #2 RN
CNA X Nursing tech
Manager MS Manager

Pertinent Interview Findings

There was only one certified nursing assistant (CNA) that day, as the other CNA called in sick. The charge nurse usually doesn’t take patient assignments; however, the emergency department was on bypass and leaders instructed all of the nursing units to make EVERY bed available.

Nurse #1 and Nurse #2 both said they were speaking to the tech at the same time while she was passing in the hall, because both of their patients needed blood draws. They had both received their admissions right around the same time.

The nursing manager thought it was a safety issue to fill all the beds in the department, as they were not adequately staffed.  However, she felt pressure from senior leaders to comply with the request and did not speak up.

The blood glucose sheet that contains the patient’s name, room number, medical record number, and date of birth was not used. Instead, a scrap piece of paper was used to record the results. This is common practice on this unit to save time, since the blood glucose sheets are rarely stocked, and they are located behind the nursing station, which is at one end of the unit.

The CNA referred to both of the patients as "your patient" when providing each nurse with results. There was an opportunity to ask a clarifying question of the tech and nurses about patient identification practices on the unit.

Timeline of Event:

March 12, 2014 (0900) RN#1 received report from ED on patient Mrs. Jones in SBAR format. Mrs. Jones was admitted with uncontrolled diabetes. Patient admits she is non-compliant with diet and medications. Last blood sugar level at 0800 was 641. Ten units of insulin were administered in the ED. RN#2 received report from ED on patient Mr. Smith in SBAR format. Mr. Smith was being admitted with chest pain, dizziness, and hyperglycemia. Last set of vitals indicated that his blood sugar was 245. Four units of insulin were administered in the ED.

(0930) Mrs. Jones arrived to 3North and placed into room 332. RN#1 obtained the admission information and instructed the CNA to repeat the blood sugar and obtain a set of baseline vitals.

(0935) Mr. Smith arrived to 3North and placed into room 333. RN#2 obtained the admission information and instructed the same CNA to obtain a set of baseline vitals and to repeat the blood sugar.

(0945) The CNA reports back to RN#1 the following: "Your new patient’s blood sugar was 149, the blood pressure was 145/100, the heart rate was 85, and the respirations were 10."

(0947) The CNA reports back to RN#2 the following: "Your new patient’s blood sugar was 525, the blood pressure was 132/80, the heart rate was 70, and the respirations were 10."

(0950) RN#2 administers 10 units of insulin to Mr. Smith for a reported blood sugar of 525. She then instructs the CNA to repeat the blood sugar within 20 minutes.

(1010) The CNA proceeds to room 333 and finds Mr. Smith unconscious. The CNA immediately pulls the cord for help.

(1011) The rapid response team arrives. Mr. Smith’s glucose was 32.

(1011) 1 mg glucagon was administered.

(1021) 25mL D50W IV push given and Mr. Smith was transferred to ICU for observation.

March 14, 2014 (1032): Mr. Smith transferred back to 3 North, events unremarkable.

March 15, 2014: Mr. Smith discharged home.

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Page last reviewed February 2017
Page originally created April 2016
Internet Citation: Event Investigation and Analysis Guide: Appendix B. Content last reviewed February 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4-guide-apb.html