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6 page paper due wednesday or thurday, the sooner the better. Looking for a thorough almost finished paper that I can revise. Thankyou! ADVERSE EVENT CASE STUDY Setting: Small medical surgical unit with 50 beds in a small suburban private hospital. June 1st 2015 1900 ER 60 year old male PB presented himself in the ER for uncontrolled back pain. He is a full code patient with active diagnosis of Stage 4, Non-Hodgkin’s Aggressive Lymphoma. His oncology reports show that his subtype was T-cell Rich, Large Diffuse B- Cell lymphoma. His last chemotherapy was on May 1st. His last radiation ended on May 15th. MRI results from before showed tumor in the bone marrow of the lumbar spine. A plain X-ray of the lumbar spine and sacrum showed a compression fracture of the L4 vertebral body and mixed osteoblastic– osteolytic changes to L4. The ER doctor decided to admit this patient to the medical surgical floor for pain control issue. June 1st 2015 2230 Med-Surg Unit Nurse CR is wrapping up her charting and getting ready to leave when charge nurse lets her know about this admission. Nurse CR is not too happy. She wanted to clock out by 2330 today and now she knows that won’t happen. She will be late again. She has a student nurse shadowing her today. She decided to get the student’s help. She asked student to get the room ready. Once patient rolled in she was trying to get through admission questions as fast as possible. She tried to initiate orders as quickly as possible. She asked student to start asking the questions while she did the paperwork. But patient was grimacing and moaning with pain. She realized Dilaudid 2mg IVP was given downstairs in ER at 2130. Once she completed the paperwork, Nurse CR rushed through admission physical assessment, admission questions, medication-reconciliation since she was getting slowed down by patient’s pain issues. June 1st 2015 2400- June 2nd 2015 0700 Patient’s pain was uncontrolled by the medications ordered which was Dilaudid 2mg IVP Q2 hours. Night nurse became very busy calling admitting physician again and again. Admitting physician MD initially did not want to order additional pain medication without seeing the patient. He was very upset with night nurse. Patient became very upset about no other pain medications. Finally after repeated calling Dr MD ordered Morphine 6 mg every 3 hours IVP. Finally patient received the dose at 4 AM. and he fell asleep. He did not want to be disturbed until he woke up. The night shift nurse noticed that RR was 16. O2 sat was 91%. So she called Dr MD again, to get order for oxygen, and placed patient on 1 litre of oxygen per nasal canula to keep his saturation above 92%. Dr MD took down her name so that he can call Director of Nursing related to communication issues with night shift nurse. June 2nd Day shift Night shift nurse gave report crying. She left home scared that she will be reported for calling Dr MD again and again. She admitted that she did not wake up patient to urinate. She documented that patient did not have any Input and Output through her shift. Day shift nurse woke up patient, and asked him to void. Patient’s vitals was stable with 1 litre O2 via nasal  cannula. His lab work was normal. Patient was upset that nurse woke him up to check if he could void. Patient tolerated 20% of his breakfast. From 10 AM he started complaining about excruciating pain 10/10 on his back again. He was upset that Dr MD did not see him yet. Day shift nurse, and charge nurse started calling Dr MD. Dr MD was looking at patients in his clinic and notified he will see the patient around 2 PM. At 1500 Dr MD wrote orders for Bone Scan, MRI of Spine and PET scan. He also ordered PCA morphine 1mg/ml with a basal rate of 0.5ml/hour, and a dose of 0.5 mg/hour with a lock out interval of 10 minutes and a max dose of 1mg morphine per hour. Heparin 5000 units Sub Q daily dose. June 2rd 2015 1500- June 4th 2015 2000 Patient refused ADL’s. Continued eating 20% of meals. No BM recorded. Urine recorded All tests completed. Results showed by June 4th evening. A bone scan with 99Tc showed increased uptake by L4, L5, and the left-side pelvis. Magnetic resonance imaging (MRI) showed a compression fracture of L4 with an enhanced mass protruding into the spinal canal causing compression of the nerve root. Positron emission tomography (PET) scan showed increased uptake of 18F-labeled deoxyglucose (FDG) over the lower lumbar region and left-side bony pelvis, consistent with the MRI findings. MD wrote for surgical consent with Dr SG for surgical consent on June 4th 2100. June 4th – June 6th 2400 Patient refused ADL’s. Continued eating 20% of meals. No BM recorded. Urine recorded Patient very upset that surgeon did not see him yet. But Dr SG’s PA notified nursing team that he was out of town and will see patient on June 7th . June 7th. 0800 Patient continued refusing ADL’s. Continued eating 20% of meals. No BM recorded. Urine recorded Patient seen by surgeon. MD wrote for consent for “Anterior vertebrectomy and posterior interbody fusion with instrumentation for spinal instability.” He expressed to nursing team he wanted to consult with peer surgeons and will then confirm date. June 8th 2100 He decided to perform surgery but heparin was already administered and hence he had to wait another day. June 9th 1400 Patient taken down to OR. He was laid down on his chest and abdomen to expose lumbar area. OR scrub nurse noticed Stage 4 decub ulcer in the lumbar area. OR nurse called MD, notified Unit Director, and CNO. She took photographs of the ulcer and saved it in patient’s chart. She also initiated a wound nurse consult.  June 9th Post-Operative Care. Patient transferred from PACU to Unit at 1800 Patient condition: Complained of numbness in bilateral lower extremity. Dr MD and Dr SG notified. Patient spiked a fever of 102.1. Vitals= 90/40, RR=12, Pulse=110, O2 sat 92% on 4 litres via nasal cannula. His PCA was still running with previous orders. Patient was losing consciousness occasionally. PM nurse GR called sepsis code, lactic acid was ordered, Dr MD and Dr SG were repeatedly called. According to GR who is a brand new nurse, she suspected patient had adventitious breath sounds and was tachycardia with arrhythmia. Dr MD wanted her to monitor patient closely. Dr SG added another antibiotic. SG asked charge nurse to assess patient with her. Charge nurse agreed with SG on her assessment. He called Dr MD again and asked if patient could be transferred to ICU. Patient was transferred at 2200. A code was called on patient around 2400. Patient died within 45 minutes. Family members were notified by ICU nurse. The case was investigated deeply because it proved incompetency of the system. CNO reported to State of California Health Auditing Agency about a stage 4 decub ulcer after 8 days of stay in the hospital. She also reported that patient was full code and died post-operatively probably from sepsis. She asked the Unit Director to come up with a plan of action so that this kind of an event does not happen again. If you are the Unit Director, how would you make changes to prevent such an adverse event in the unit. Here are pointers based on which you should write the paper. 1. Leadership Style / Styles used 2. Investigation 3. Strategies /Policies changed implemented: a. Education b. Staffing c. Workflow d. Communication e. Documentation f. Interdisciplinary Team and plan of care g. Staff Discipline 4. Anticipated outcome of these strategies/Objective measurement Submit a paper in APA format (minimum 8 pages including Title page and Abstract ). Minimum 3 Peer reviewed journal reference. Please see attached grading Rubric. Grading Rubric: Title page Abstract Header Footer 5 Minimum pg 5 APA format 5 References 5 Intro and Conclusion 5 Leadership Style 10 Investigation 10 Strategies 40 Outcome 15