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Case Study 1 (cont.)
That morning the nurse made a series of errors that resulted in the death of a patient
1) she failed to place the armband on the patient's wrist
2) at 11:30 pm she removed the patient's medications
from the pxyis along with the epidural medications (a
combination of bupivacaine and fentanyl) that she
thought might be needed later and placed them on a
counter in the birthing room
3) after starting an IV on her patient at 12:06, grabbed
the bag of what she thought was penicillin and added
it to the IV without checking the bag, scanning the
patients wristband or using the bar-code
administration system
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