CASE STUDY—BEWARE: One Emergency May Hide Another! A hospital submitted a report to the State Board of Nursing reporting that an RN had been terminated after the death of a patient following surgery for a tubal pregnancy. THE NURSE'S STORY—SALLY SIMMS, RN I had worked the medical-surgical units at the General Hospital ever since graduating from my nursing program 4 years before. This was the worst night, the worst shift, of my nursing career. I was assigned to care for eight patients that night, which is not an unusual number of patients, but they all were either fresh post-ops or so very sick. Four patients had just had surgery that day. One patient was on a dopamine drip to maintain his blood pressure, so he needed frequent monitoring. One patient was suspected to have meningitis, one patient had pneumonia, and a patient with suspected histoplasmosis completed my assignment. One of my post-op patients was Betty Smith, a young woman in her early thirties who had laparoscopic surgery late in the day. She had been transferred from the recovery room late in the evening shift and was very uncomfortable when I first made my rounds. At 12:05 am, I called Betty's physician because she was vomiting and thrashing in bed. Per his order, I medicated the patient with Phenergan. The next time I checked on Betty, she seemed to be more comfortable, but I realized that her IV had infiltrated. I was really overwhelmed with meeting the needs of all my patients, so I asked Joan Jones, the charge nurse, to restart Betty's IV. It was about 2:00 am when Nurse Joan restarted the IV. I had been able to pretty much stay on top of everything at that point in the shift, and by 2:30 am I had assessed all my patients, given pain medications, and called four physicians to update them regarding their patients and for various orders. I thought things were settling down. I thought wrong. Mrs. Holmes, the patient with histoplasmosis, seemed a bit off from when I had cared for her the previous two nights. Mrs. Holmes' vital signs were unstable and her O2 saturation was only 80%. I notified her physician and he ordered stat arterial blood gases. The lab called with the results, and they were alarming. Mrs. Homes was losing ground, and her physician ordered us to transfer her to the ICU. I was preoccupied with accomplishing the transfer and accompanied Mrs. Holmes to the unit. I returned from the ICU at about 3:50 am. On my return, I first checked the patient who was on dopamine, medicated another patient for pain, and did visual checks on the rest of the patients who all seemed to be sleeping. I began my charting. At 6:05 am, I went to start IV antibiotics on Betty's roommate, and to my horror discovered Betty was not breathing. I called the code. The first time I discovered that Betty had had a low blood pressure and elevated pulse was when I checked the vital signs sheet when the ER physician (who responded to the code) asked how Betty's vital signs had been during the shift ...

1. CASE STUDY—BEWARE: One Emergency May Hide Another!
A hospital submitted a report to the State Board of Nursing
reporting that an RN had been terminated after the death of a
patient following surgery for a tubal pregnancy.
THE NURSE'S STORY—SALLY SIMMS, RN
I had worked the medical-surgical units at the General Hospital
ever since graduating from my nursing program 4 years before.
This was the worst night, the worst shift, of my nursing career.
I was assigned to care for eight patients that night, which is not
an unusual number of patients, but they all were either fresh
post-ops or so very sick. Four patients had just had surgery that
day. One patient was on a dopamine drip to maintain his blood
pressure, so he needed frequent monitoring. One patient was
suspected to have meningitis, one patient had pneumonia, and a
patient with suspected histoplasmosis completed my
assignment.
One of my post-op patients was Betty Smith, a young woman in
her early thirties who had laparoscopic surgery late in the day.
She had been transferred from the recovery room late in the
evening shift and was very uncomfortable when I first made my
rounds. At 12:05 am, I called Betty's physician because she was
vomiting and thrashing in bed. Per his order, I medicated the
patient with Phenergan.
The next time I checked on Betty, she seemed to be more
comfortable, but I realized that her IV had infiltrated. I was
really overwhelmed with meeting the needs of all my patients,
so I asked Joan Jones, the charge nurse, to restart Betty's IV. It
was about 2:00 am when Nurse Joan restarted the IV.
I had been able to pretty much stay on top of everything at that
point in the shift, and by 2:30 am I had assessed all my patients,
given pain medications, and called four physicians to update
them regarding their patients and for various orders. I thought
things were settling down. I thought wrong.
Mrs. Holmes, the patient with histoplasmosis, seemed a bit off

2. from when I had cared for her the previous two nights. Mrs.
Holmes' vital signs were unstable and her O2 saturation was
only 80%. I notified her physician and he ordered stat arterial
blood gases. The lab called with the results, and they were
alarming. Mrs. Homes was losing ground, and her physician
ordered us to transfer her to the ICU. I was preoccupied with
accomplishing the transfer and accompanied Mrs. Holmes to the
unit. I returned from the ICU at about 3:50 am.
On my return, I first checked the patient who was on dopamine,
medicated another patient for pain, and did visual checks on the
rest of the patients who all seemed to be sleeping. I began my
charting.
At 6:05 am, I went to start IV antibiotics on Betty's roommate,
and to my horror discovered Betty was not breathing. I called
the code. The first time I discovered that Betty had had a l ow
blood pressure and elevated pulse was when I checked the vital
signs sheet when the ER physician (who responded to the code)
asked how Betty's vital signs had been during the shift. The
nurse's aide who was assigned to monitor Betty had not
informed me, and I had not checked the vital signs sheet.
It was such a terrible night; I was so busy with the transfer and
caring for the other patients. Betty just had an outpatient
procedure; if she had been earlier on the surgical schedule, they
would have sent her home. I did not physically check her vital
signs, and the aide did not report the elevated pulse and low
blood pressure. I depended on the aide—my mistake. I know I
was responsible.
I was terminated from employment and reported to the board of
nursing. I have taken myself out of nursing; something died in
me when I found my patient.
EMPLOYMENT EVALUATIONS
An evaluation conducted a few weeks before the incident
showed mostly good ratings (11) with three excellent ratings.
The hospital would consider reemployment if Ms. Simms
improved her critical thinking skills.
PATIENT MEDICAL RECORD

3. Surgery Notes—Laparoscopy to remove unruptured ectopic
pregnancy from distal portion of the fimbriae with estimated
blood loss of 150 cc, three references to homeostasis, two
references to cautery, patient “… to recovery room in excellent
condition.”
Recovery Room Nurse's Notes—In recovery 2110 to 2300,
initial post-op flow sheet noted at 2210 BP 124/74, pulse 94; at
2225 BP 123/65; at 2240 BP 107/85, pulse 123. Assessment
signed at 2220 “abdomen distended with few faint bowel sounds
… patient shivering, c/o [complained of] abdominal pain,
medicated ×3 [three times] with IVP Demerol, total of 50 mg.
Patient awake, three dressings dry. No c/o N/V/D.” [No
complaints of nausea, vomiting or diarrhea.]
Medication Record—Patient received Demerol 50 mg. with 25
mg Phenergan IM at 2215 and 0200.
Cardiopulmonary Resuscitation Record—Compressions noted at
6:08 am. [RN had initiated code at 5:55 am], MD arrived at 6:15
am, patient intubated at 6:20 am, patient administered atropine
×3, Eppy [epinephrine] ×5 [five times], bicarbonate [of sodium]
×2 [two times]. Pacemaker never captured. Patient never had
return of spontaneous pulses and pronounced dead at 6:38 am.
Death Certificate—Immediate cause of death was
hemoperitoneum due to postoperative hemorrhage of placental
tissues after salpingotomy for a right tubal ectopic pregnancy.
BOARD ACTION
Ms. Simms entered into a consent agreement with the board of
nursing, admitting that her conduct constituted a failure to
practice in accordance with acceptable and prevailing standards
of safe nursing care. Nursing standards cited were failure to
assess and document the health status of the patient, failure to
provide ongoing patient monitoring, and failure to communicate
appropriately with members of the health care team.
Ms. Simms' license was probated with stayed suspension for 2
years, with requirements for successful completion of ordered
education including an advanced assessment course at an
educational/collegiate institution, continuing education hours in

4. risk management/legal issues in nursing (in addition to
continuing education hours required for license renewal). Order
noted RN's voluntary evaluation by a mental health care
professional and her compliance with all aspects of the
treatment plan. Other terms included quarterly reports from
nursing employer and self-reports. Ms. Simms was required to
appear in person (as requested) for an interview with the Board
or a board-designated representative.
COMMENTARY
This case example illustrates a cascade of clinical events that
caused errors in clinical judgment, all of which are related to
work overload and consequent lack of surveillance and
monitoring of the patient. Nurse Simms made faulty
assumptions that the young patient with a tubal pregnancy was
her least acute patient. Of course the patient is the primary
victim, but Nurse Simms also suffered greatly from this tragic
incident, which was precipitated by a collection of untoward
events and work overload.