Case Study Analysis

Active Participation 1


Nirali Makwana

Polk State College

Case Study: Failure to adequately assess and monitor the patient post-operatively resulting in the patient’s death

Preferably, a visit to the medical facility for a certain health condition is not expected to worsen the ailment but to alleviate it. Unfortunately, this is not always the case in most hospitals. Nursing malpractices and errors have proved disastrous towards the patient’s safety and life as described by several studies. Nosocomial or Hospital Acquired Infection can occur as a result of nursing malpractices and the lack of keenness when addressing critical health conditions on a patient in the medical facilities. This may occur when nurses and physicians fail to maintain safety measures when attending to a patient (Hågensen et al., 2018). Lack of proper hygiene can also lead to hospital-acquired infections and often cause death or worsen the condition. In most malpractice instances, nurses end up responsible for their failure to maintain top-notch care to the patient, and negligence can be punishable by law. An excellent example of medical malpractice has been provided in the above case study about the failure to adequately assess and monitor the patient post-operatively resulting in the patient’s death.

This case study is about an older man aged 67 years that underwent right knee replacement procedure. After the procedure was conducted on him, he was transferred to the post-anesthesia care unit where he could recover. While in this unit, an epidural catheter was inserted to manage pain upon operation. The doctor also treated the patient with ephedrine for low blood pressure while in the post-anesthesia unit. Following successful treatment of the hypotension episode with ephedrine, the patient was then discharged to an inpatient medical-surgical care unit. A nurse who was working on the post-acute critical care unit was reassigned to oversee and monitor the patient’s floor, whereby she claimed to be conversant with her role in nursing. However, she understood that the direct care of the older man was not her role, but the role of the co-defendant licensed practical nurse. About three hours after the patient arrived in this new unit, he was unable to endure the prescribed respiratory therapy due to symptoms of nausea. The LPN in charge of the client later found him cyanotic, and as a result, he came unresponsive. When she called for help, the defendant nurse and other respondents arrived immediately. They took the patient to the Intensive Care Unit, where he was intubated and taken care up before dying. His death was due to anoxic encephalopathy since CPR was not initiated immediately.

This case is a significant example of medical malpractices in nursing, where the defendant nurse failed in her role to clarify her work assignment. Furthermore, it is evident that she failed to notify the physician of the changes that she noticed in the patient’s condition. The deteriorating condition of his health could have been reported once noticed to save his life. This is not a special case in contemporary healthcare system since many patients have suffered and still suffer in the hands of careless nurses. It is the role of the nurse to supervise the LPN’s care of unstable patients (Hågensen et al., 2018). As well, following post-operative physician orders by the nurse would alleviate medical malpractices and errors. Furthermore, nursing code of ethics requires nursing professionals and caregivers to avoid negligence and malpractices that might cost patient lives and also land them into serious consequences.


Hågensen, G., Nilsen, G., Mehus, G., & Henriksen, N. (2018). The struggle against perceived negligence. A qualitative study of patients’ experiences of adverse events in Norwegian hospitals. BMC Health Services Research18(1), 302.

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