30 minutes – Leah Coufal

1. What system issues might have contributed to this outcome?

When it comes to medication every patient has a right to education, and in this case, this was a right that was not granted to this family. This is clear by the words spoken by the mother of Leah Coufal, “I took her to a doctor and they told me you can do something about it but they didn’t tell me there was no need to and that it was really a measured surgery”. Another system issue that contributed to this problem was overmedication. The reason for the medication was the patient complaining of pain, but even after seeing that the medication was having no effect, the staff chose to continue increasing the medication until the father shared his concerns and disapproval of the medication amount. At that point the nurses decided to change the medication, the problem this time was the medication dosage most probably fell out of the recommended dosage for the patient who was a child. This can be understood by the comparison made by the mother of the patient, “turned out that the resident had written an order for 2mL of Ativan every 2 hours. If you’re familiar with that event 2mL of Ativan would put a grown man to sleep”. Lastly, there was a poor job of monitoring the vitals of the patient after the surgery. In our current society due to newer technology monitoring has been made easier, that way even on busier nights there is a monitor monitoring the vitals of the nurse and alarming the nurse of negative changes. After the surgery, no monitor was assigned to her, if there had been a monitor monitoring her vitals the nurses could have begun to take action the moment things started to look bad and could have even prevented the death.