RMF Teaching Case M3-1 - Download
Claudia Hernandez, a nurse visiting a post-op floor, hears beeping as she is passing the room of 63-year-old Desmond Flora. Nurse Hernandez discovers that Mr. Flora has received an analgesic overdose. When the nurse alerts the regular staff on that floor to Mr. Flora’s overdose, they tell her those alarms are “like the boy who cried ‘wolf.’”
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RMF Teaching Case M3-2 - Download
During an emergency C-section, the anesthesia team has difficulty intubating 29-year-old Laura Small. Amidst acrimonious debate between the surgeon, anxious to begin the procedure, and the anesthesiologist, struggling to get Ms. Small’s airway cleared, the baby is delivered. The mother’s uterus is noted as blue, and her vital signs rapidly deteriorate. A Code Blue is called and CPR begun. Still waiting for the airway team, an obstetrician attempts a tracheostomy. After defibrillation and medication restore a normal sinus rhythm, it is estimated that Ms. Small was anoxic for at least 10 minutes.
She is given succinylcholine and Pentothal followed by multiple attempts at tracheal intubation (with oxygen given in between) all resulting in esophageal intubation. Five attempts to visualize the cords are unsuccessful. Mask ventilation is unsuccessful. At that point, her oxygen saturation begins to drop significantly (from 90% to a reading of less than 50%).
The anesthesiologist asks for a Combi-tube, but none is readily available in the room.
With Ms. Small’s oxygen saturation level rapidly decreasing, Dr. Tobin wants to begins the skin incision, while another individual in the room places a call—via the beeper paging system—to the “airway team” of surgeons for a tracheostomy. The individual carrying the “airway beeper” was not immediately available on site.
The infant is delivered three minutes after the initial skin incision with Apgars of 5, 6, and 7.
The surgical airway team members reach the floor, but have problems identifying which room they should go to in the delivery suite. They eventually arrive approximately nine minutes after the first call, complete the tracheostomy after controlling bleeding from the prior transverse incision, and place an endotracheal tube.
After a 12-hour shift and no lunch, Martina Pellos, an obstetrics nurse who is assisting in the emergency, is directed to rapidly administer phytonadione to the baby. Nurse Pellos reaches for an ampule of phytonadione from the set of bins at the side of the room holding several medications commonly used in the delivery suite. After injecting the medication, she notices that she has inadvertently given the baby Methergine.
RMF Teaching Case M3-3 - Download
An ICU nurse—momentarily distracted by a question about another patient—incorrectly programs a brain-clot patient’s IV heparin pump to administer the 20,000 unit dose to be delivered in two hours rather than in 24 hours. The error goes undetected for six hours; the patient is left with hemiparesis and impaired speech.
