All health care organization's goal is patient quality and safety. Unfortunately, great national reviews of patient charts estimate that approximately 10% of hospital admissions are associated with an adverse event (defined as an injury resulting in prolonged hospitalization, disability or death, caused by healthcare management). Adverse events are medication errors or drug events, wrong-site surgery, surgical injuries, misdiagnosis, to name a few.Underreporting of medical errors results in several problems for healthcare organizations, including decreased information about what causes patient harm, lack of knowledge about how to address issues of harm and patient safety, misunderstanding of the extent of patient harm, and inability to plan and prepare for the future. Apart from having a significant impact on patient morbidity and mortality, adverse events also result in increased healthcare costs due to more extended hospital stays. Furthermore, a substantial proportion of adverse events are preventable. Through identifying the nature and rate of adverse events, initiatives to improve care can be developed. (Rafter et al., 2014). Situation Background A.B is a 76-year-old female who came into to Emergency Room past eight in the morning due to shortness of breath and is admitted for congestive heart failure in the Universal Care Unit. She reported having a history of hypertension, diabetes mellitus, and congestive heart failure. The initial blood sugar result in ED was 150 mg/dl in which no insulin coverage is given per protocol. Upon arrival at the unit, the patient requested a snack and is given apple juice and crackers by the admitting nurse. While the primary nurse is doing her admission interview, the primary doctor examined the patient, verbally instructed the nurse to recheck blood sugar before dinner time, and informed the patient that a Lasix dose would be given to remove fluid build-up
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