Renal failure caused by Vancomycin toxicity
Type: Research Paper
Subject: QUALITY & INFORMATICS IN PRACTICE - Root cause and analysis
Subject area: Nursing
Education Level: Undergraduate/College
Length: 4 pages
Referencing style: APA
Preferred English: US English
Spacing Option: Double
Instructions: this assignment is the second part of a series of assignments related to your final course immersion project. the first part of the assignment series was choosing an appropriate topic. the root cause analysis (rca) assignment begins in module 2 but is due at the end of module 3. the goal of this paper is to apply the principles of the root cause analysis to a problem or opportunity for improvement in your workplace. this assignment requires systems thinking and problem solving by identifying contributing factors or root causes to an adverse event without assigning blame to individuals. guidelines briefly present the situation, error/adverse event or case study. this is the "what happened?" portion of the rca. do not include any organizational, patient or staff identifiers. be sure to include the impact on the patient, family and staff involved. next, present "why did it happen?" portion of the rca. identify the contributing factors to the incident. include a cause & effect diagram (fishbone diagram) to illustrate the contributing factors to the adverse event include the fishbone diagram as an embedded image or appendix in your paper. fishbone diagram template apa format with a title page. maximum 4 pages in length (excluding title page, references & appendix). this paper will automatically be submitted to turnitin (plagiarism protection software), you may view the turnitin results by clicking on the colored icon next to your assignment.
Focus: my case scenerio:- patient john snow, 77 years old, lives at home with his son and was brought to the ed for increased weakness and malaise for two days. he came to the emergency room. when in the emergency room he was noted to have fever 102, hr 102, resp 18, bp 119/63, wbc 21, crp 34. bun 24 and creatinine 0.94. patient was later admitted to a medical surgical unit and had been started on two antibiotics, zosyn and vancomycin. he had already received the first initial doses in the emergency room. his chest x-ray was negative, he denied pain beside just feeling weak. his urinalysis was negative, blood cultures still pending. while on the unit the patient started to have a change in mental status (confusion), low bp 79/40, increased heart rate and fever. his preliminary blood cultures had come back positive. a rapid response was called. patient was given iv fluid bolus but the blood pressure was not getting better. a decision was made to send him to the icu for further evaluation. he got vasopressors to help with his blood pressure. he had poor iv access and a picc line was placed. meanwhile the patient continued with the 2 iv antibiotics. patient had his vancomycin trough done once since he was admitted. it was 15 which was within normal limits. he was in the icu for one day then he was downgraded to a step down unit when his blood pressure and mentation got better. he also spent a day in the step down unit then was brought back to the medical surgical unit. he now was in acute renal failure. bun 84 and creatinine 3.15. he received 6 doses of vancomycin without a trough level check. normally with every 3rd dose or depending on what the physician orders is when the trough is checked. the patient transferring from unit to unit, had 3 different primary attending physicians, from the intensivist to the regular hospitalist doctor. there were no orders to check the patients vancomycin trough level. as one of the nurses was getting report on the patient and noted that the patient had not had a trough done for the last six doses. a random trough was ordered by the physician, which came back at 35 and normal range is between 10 and 20. a variance or an incident report was done. the following days the patient had vancomycin on hold with continued daily random trough checks. his bun and creatinine continued to get so elevated, he had to get a nephrology consult and he was started on temporary hemodialysis. the patient and family were informed of the renal failure. patient became depressed because he came in with one problem and ended up with more issues. a psychological consult was also ordered for him.
