Safety and Quality in Healthcare

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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