Ms. Elena Case

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1) The first and obvious issue presented in this case is the lack of attention the staff member received from residence administrator with regards to the patient’s blood sugar level being too low. At this point, all attention should have been focused on analyzing Ms. Elena’s current state and evaluating if providing her regular treatment was to be followed. The second alarming issue that arose was that the staff member was not properly trained in administering the medication using a different device. If the agency nurse knew that the regular insulin pen Ms. Elena used broke, he/she should have been more aware that the staff members may need additional training using unfamiliar equipment. This issue also worsened the next problem seen in this case, incorrect dosage. There is absolutely no reason that Ms. Elena should have been given a dosage nine times stronger than her prescribed amount. Although many of the previous issues needed more administrative correction, this problem lies solely in the hands of the staff member. Overall, although there were …show more content…
Elena – patient eventually died due to negligence from residence administration and incorrect medication administration from the staff member.
- Staff Member (AMAP) – administered incorrect dosage of medication and eventually lead to the death of Ms. Elena.
- Licensed Agency Nurse – person who was responsible to train the AMAP staff members and was not aware that the AMAP staff member was not trained in administering insulin through different devices.
- Residence Administrators – oversee the operations of the facility and address staff member concerns. Their negligence to check and verify Ms. Elena’s health, as per AMAP concerns, before her 10pm medication administration on July 2nd lead to her eventual death days later.
- Local pharmacy – was to have adequate supply of insulin pens
- The Commission – recommended agencies mandate all AMAPs receive rigorous training in diabetes
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