Safety and Quality in Healthcare
Assignment 1 – Critical analysis of a Clinical Scenario (1,500 words)
An ambulance was dispatched to attend a 55 year-old patient with heart failure in the
community. While treating this patient, a paramedic mistakenly pushes 4 milligrams
of intravenous norepinephrine instead of the intended lookalike vial of 1 milligram of
bumetanide (Bumex®). The patient immediately develops a supraventricular
tachycardia, becomes hypertensive, and deteriorates into ventricular fibrillation.
Resuscitative efforts are unsuccessful; the patient is pronounced dead on arrival at
the ED.
Identify and outline the errors made by the paramedic in this clinical scenario.
Analyse the contributing factors to human and system errors and apply your
findings to this case.
Explain the actions you would recommend to improve patient safety and
prevent a similar error by another paramedic.
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