Reference no: EM133527676

Case Study: Analyzing What Happened to Margaret

Margaret is an elderly woman with dementia who has been admitted to an academic medical center for breathing problems.

Peter is a well-respected nurse on the medical unit. He has been working there for five years, and he's recently been helping new nurses get oriented to work in his part of the hospital. Today, he is working with Amy, who just became a registered nurse.

Jorge, a respiratory therapist, is called to see Margaret to help with her breathing. He notes that she is not getting enough oxygen using just the nasal prongs, and he switches her to an oxygen mask, which improves her symptoms. Jorge sees Peter in the hallway and says, "Hey, Peter, I upped her oxygen," as they pass each other on the way to their next tasks. It is a busy day for Jorge, who figures he will write his notes in the chart later.

At 3 PM, Margaret is scheduled to go for a test in the radiology department on the other side of the hospital. Teddy, the patient transporter, arrives to take Margaret to her test. Peter, the experienced nurse, is in another patient's room, assisting one of the doctors with the placement of a sterile central line. When Teddy asks if there are any special concerns with Margaret, Amy, the new nurse, replies, "No, she's all set!" (If Amy had known about Margaret's oxygen mask, she would have accompanied her to the test.)

While being transported, Margaret knocks her mask off her face. When she arrives in the radiology department for her test, she is not breathing. Teddy calls the code team, but they are unable to resuscitate her.

Remember the case of Margaret (and the caregivers Peter, Amy, Jorge, and Teddy) that we introduced in the last lesson? If not, you can review it here now.(opens in a new tab)

Question: Who do you think should be involved in the RCA2 team?