Reference no: EM133341844

Case Study: Nora Boström died in a hospital room, her arms clenched around her mother's neck, on November 22, 2013. It was 22 days before her fourth birthday.

Nora had blonde, curly hair and a big laugh, and seemed to hate wearing pants - pictures of her as a toddler show her wiggling right out of them. Nora was also born prematurely with underdeveloped lungs. A few months before her third birthday, she underwent a small surgical procedure that placed a thin, snakelike tube running through her chest to her heart. Doctors used it to pump medicine into her bloodstream that would help her lungs grow.

The tube is called a central line catheter, and doctors insert millions of them into patients each year. Because they run straight to the heart, central lines are the fastest, most effective method of delivering often lifesaving medication. But if bacteria manages to get into the central line - when a nurse changes a dressing or injects a medication - it can quickly become a bloodstream infection. At best, these infections cause suffering for already-sick patients. At worst, they kill them.

Nora had four central line infections in her last year of life. "Every line infection just took more out of her, and more out of her, because it weakened her heart," Claire McCormack, Nora's mother, says. "It just weakened that perfect heart."

Claire and Thomas say they saw nurses who didn't wash their hands before using Nora's central line. "We also observed nurses ...touching bedrails after they put their gloves on and then not changing their gloves before accessing the line," they wrote in a letter to the hospital after Nora's death.

Questions:

1. What mistake/lapse/ rule ignore did you take part in? What was your mindset and why do you think it occurred? How could you prevent this from happening again?

2. Now think of the nurses in the above scenario. Are there similarities between what might have caused their error(s)/oversight and what caused yours?