Case Study #1
A 55-year old female was transported to the floor after recovering from a surgical procedure. An
epidural catheter with morphine was placed for post-operative pain control. Upon arrival, the patient
complained of nausea and a headache prompting the on-call physician to prescribe, %merol 75mg
every three hours for pain. he preprinted medication orders from anesthesia stated ¯ narcotics,
sedatives, or other respiratory depressants to be given during infusion of epidural medication and for
12 hours after epidural is discontinued except by order of anesthesia. he nurse had not reviewed
this order prior to obtaining and administering the new order for Demerol, a narcotic.
Twenty minutes later, the patient was found unresponsive and aggressive resuscitation efforts were
implemented, resulting in intubation and mechanical ventilation of the patient. When brain activity
was not found, the family made the decision to take the patient off of life support and the patient died
shortly thereafter.
The patientàfamily filed a lawsuit claiming negligence in administering the medication. A verdict was
entered against the nurse for nearly $4 million.
A. Event Identification
B. Risk Assessment Reference
C. Response Plan
D. Control Activities
E. Information and Communication
F. Monitoring
G. Recommendation
H. Conclusion

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