The Unfortunate Hospital Experience for Mr. B

Identification of Events

* Mr. B presents to the Emergency Room with complaints of Left hip and leg pain * His son is at the bedside * Dr. T assesses Mr. B determining that he needs to set Mr. B’s hip at the bedside. * Dr. T orders moderate sedation * Mr. B takes oxycodone for chronic pain * Nurse J is assigned to care for Mr. B * Nurse J administers medications per Dr.T’s orders * 5 mg of Diazepam * Dr. T assesses Mr. B’s sedation level. Mr. B needs more sedation * Dr. T orders additional sedation medication * 2mg of Hydromorphone * Nurse J administers additional sedation medication per Dr. T orders * Mr. B is not fully sedated and Dr. T orders a 3rd dose of sedation medication * 5 mg of Diazepam and 2 mg of Hydromorphone * Dr. T assesses Mr. B. * Mr. B is fully sedated for the procedure * Dr. T reduces and sets Mr. B’s left hip * Mr. B’s procedure is completed. He appears comfortable and remains sedated * The Emergency Room receives an emergency dispatch call * Pt. in respiratory distress * Nurse J needs to respond to the call. * Nurse J puts a blood pressure cuff on Mr. B with 5 minute cycles and places the pulse oximeter on Mr. B * Son remains at bedside * Nurse J leaves the room to care for the patient in respiratory distress * Mr. B’s pulse oximeter alarm goes off “ low O2 “ * LPN responds to the alarm. LPN disables the alarm, recycles the BP machine and leaves room * Mr. B’s son locates Nurse J and states the machine keeps alarming * Nurse J responds and assesses Mr. B * Mr. B is pulseless and not breathing * Code Blue is called * Mr. B is subsequently found to be in V fib arrest. * Required defibrillation and intubation