Nursing Case Study Josie's Death

For most people, medical facilities are considered to be safe and healing centers, where people visit to improve their wellbeing. But it is very unfortunate that lot deaths are caused by errors committed by medical teams in this facilities. Every year, almost 144000 people die as a result of medical errors (The Leapfrog Group2015), which also took the life of an eighteen months old Josie in 2001 at John Hopkins Hospital. Josie’s death is very painful and sad as it is a result of avoidable medical errors. Josie’s death would have been prevented if she was provided with adequate care and close attention while she was exhibiting some changes in her behavior. Also, listening to the concerned mother who knows her daughter better could have also help prevent Josie’s death. and likewise, effective communication among the care providers would have made a great difference in the outcome of Josie’s care.

If I were to be Josie’s nurse, I would assessed her immediately for signs and symptoms of dehydration after seeing her cried for drinks, and sucked on wash cloth that was used for bathing her.

I would take the step of hydrating Josie by obtaining a swallow screen order from the physician to determine how well she can tolerate fluid. I would as well obtain an order from the physician to start Josie on IV fluid if she was unable to receive anything through her mouth. Also, l would listen to Josie’s mother about her concerns, since she knows her daughter better than anyone else, and had stayed with Josie since her admission. In addition to this, I would assess the Josie according to her mother’s report that Josie’s eyes were rolling back, and call the physician for further interventions. It is my responsibility as a nurse to know if a particular medication is safe to be given to my patient and to check with the prescriber of the medication for patient’s

safety.
Furthermore, good communication is vital in healthcare, especially among medical teams to provide adequate and error free care to patients, while inadequate or lack of good communication is very dangerous, as it resulted to Josie’s death. Communication would have prevented Josie’s death if the physician who discontinued the medication had documented it to back up the oral order, as the nurse would know about the discontinuation. Also, Josie’s death would have been prevented if the nurse at the previous shift had charted the changes, and communicated it to the incoming nurse during the change of shift report. In addition to this, the primary nurse should have listened to the mother’s concern, communicate it to the charge nurse, and call the doctor for further clarification of the medication before administering it.
In conclusion, medical error is a preventable condition that kills thousands of people every year. And it could be avoided if everyone in the medical team works together with patients and families to provide exceptional care. Josie’s death could have been averted if timely assessment and adequate care was provided when Josie’s mother complained about new symptoms that her daughter was exhibiting. And likewise, effective communication among the medical team members would have prevented the nurse from administering the medication. It is very sad that Josie was a victim of this medical loophole, and hopefully her death would bring more awareness and resolution to this problem.