Reference no: EM133795665

Assignment: Leadership Development

Joan, a 34-year-old woman who is pregnant, began feeling ill. She was concerned for the safety of her unborn baby and went to her local hospital emergency department. She was experiencing abdominal cramping, fever, and shortness of breath. She was given intravenous (IV) antibiotics and rushed to surgery for a cesarean delivery because she was near term and the fetus was in distress. Upon delivery, the amniotic fluid was foul smelling and chorioamnionitis and an infection of the amniotic sac was diagnosed.

After delivery, she was transferred to the postpartum floor as a standard post cesarean client. Several hours later, she was found to be lethargic with low blood pressure. Blood cultures were drawn, and IV fluids were administered. Several hours later, the blood work revealed that the client had gram-negative bacteria, and the team realized that she was in septic shock.

Task

A. What was the cause of the septic shock?
B. Why do you think septic shock developed?
C. What client safety concerns do you have with this scenario?
D. What potential medical errors could have occurred?
E. What communication errors might have occurred?

Remember Joan, the patient who had an emergency cesarean delivery and then went into septic shock? It was discovered that the emergency department care provider had prescribed a one-time dose of antibiotics almost 24 hours earlier and no further treatment was ordered.

As the emergency department does not follow clients after they are admitted to the floor, a one-time dose of IV antibiotics was standard procedure. The error here was related to information not communicated during handoff. The client deteriorated and was eventually transferred to the intensive care unit where she was intubated. She eventually made a full recovery, but this preventable error resulted in a longer and more complicated client stay.