Case studies for Assessment Task 2 NRSG378 2025 Semester One

NRSG 378 Assessment Task Two: Root Cause Analysis- Case Study A Background

At approximately 4:45 pm on a weekday, Ms. A, a registered nurse (RN) heard unusual noises from a residents room at a residential aged care facility. Initially, the RN (Ms. A) dismissed the noises, as the resident often made noises in her bedroom. RN (Ms. A) grew concerned after the noises persisted. RN (Ms A). and a colleague, RN (Mr. B), checked on the resident, Ms. D.

They found Ms. D lying on her side on the floor, between her bed and a chest of drawers. She stated she had tripped over a basket for storing personal items. The room was noted to be cluttered despite regular assistance from staff with tidying. Multiple items were found on the floor, many of which may have contributed to the fall.

Immediate Response

When asked if she was injured, Ms D reported she could not get up and requested an ambulance. Despite her request, RN (Ms A) and RN (Mr B) decided against calling emergency services. Historically, prior incidents where ambulances were called for Mrs D did not uncover significant health concerns. The RNs assisted her into a recliner chair, during which she moaned but appeared comfortable once seated. An icepack was applied to her lower back, and the RN nurse initiated paracetamol for pain. The RN decided not to notify the on-call GP. Neither the RNs nor PCAs re-assessed Ms D until dinner because the shift was busy with other residents' call bells and medication administration rounds.

Later, Ms. D joined other residents briefly at dinner and appeared to return to her normal activities, including knitting. After dinner and overnight, Ms. D was only observed (sighted) every 4 hours, and she appeared to be comfortable. Overnight progress notes stated Ms. D refused her medications and vital signs assessment. The progress notes also indicated this was unusual behaviour for Ms. D.

The Following Morning

At 8:00 am, the incoming RN (Mr. E) found Ms. D difficult to rouse. She appeared pale and cold to the touch, with visible injuries, including torn skin on her toes and shins with minor bleeding. Ms. D reported a second fall during the night, resulting in severe pain.RN (Mr. E) completed a set of vital signs (BP 73/35 mmHg, HR 125bpm irregular, Temp 35.7C, RR 28bpm, shallow, Oxygen saturations 92% on room air). Despite being able to respond verbally to questions, RN (Mr. E) documented in progress notes that the patient appeared abnormally confused. An ambulance was called.

Ms D was transferred to a hospital where diagnostic imaging revealed unstable cervical (C1- 2) spinal injuries requiring urgent care. Despite surgical interventions, her condition resulted in quadriplegia. She was transitioned to palliative care and passed away two days later.

Possible Root causes

• No process for providing and escalating care for unwitnessed falls

• Inadequate response through assessment to an acute deterioration

• Inadequate staffing based on the workload and acuity of the residential aged care facility

NRSG 378 Assessment Task Two: Root Cause Analysis- Case Study B Background

Ms. R, a 58-year-old patient, was admitted to the hospital for the acute management of a deep vein thrombosis (DVT). Her past medical history includes Type 2 diabetes mellitus, hypertension, and chronic kidney disease (stage 3), her weight was 80kg. Upon admission, Ms. R was prescribed:

• Enoxaparin 80 mg subcutaneously twice daily (Treatment for DVT)

• Metformin 500 mg twice daily

• Amlodipine 5 mg once daily

• Paracetamol 1g every 6 hours as needed for pain

Incident Timeline

1. Day 1: Nurse A administered R's scheduled medications as ordered during the evening medication round (2000hrs).

1. Day 2, morning shift: When Nurse B went to administer Enoxaparin to R, she noted a moderate sized bruise in her abdomen. She attributed this to the previous Enoxaparin injection. Ms R also complained about having new mild abdominal tenderness and feeling more fatigued. As the symptoms were mild, Nurse B administered PRN paracetamol and encouraged Ms. R to take more rest in the morning. Nurse B did not report the new changes to the medical team at the time.

1. Day 2, at 1300: R's abdominal pain worsened. Her blood pressure was recorded as 92/60 mmHg, heart rate was 110bpm regular and respiratory rate was 28bpm, shallow. Nurse B paged a junior medical officer (JMO) who responded after an hour and ordered a routine blood profile (see below), chest x-ray and frequent vital sign monitoring. Nurse B discussed this plan during handover with Nurse C, who was commencing the afternoon shift.

1. Day 2, evening: The blood panel results are as follows:

The JMO called the ward after reviewing the bloods. Nurse C was on break, so Nurse D took the call. The JMO verbally requested to cease the enoxaparin. When Nurse C returned from break, she was unaware of the verbal order and administered another 80mg dose of Enoxaparin.

5. Day 3, Early Morning: R became hypotensive (BP 78/54 mmHg), tachycardic (HR 131bpm, regular) and reported worsening headache and abdominal pain. A CT scan revealed a significant retroperitoneal bleed. She was transferred to the intensive care unit (ICU) for urgent resuscitation and intervention.

5. Outcome: R required emergency surgery to control the bleed and spent two weeks in the ICU. Although she survived, she experienced a prolonged recovery, including significant deconditioning and new-onset anxiety related to her hospital stay.

Possible Root causes

• Inadequate processes for urgently ceasing medications (phone orders)

• Inadequate processes for medication review pending related pathology results

• Inadequate recognition and response to signs of acute deterioration (bleeding)