Case Study Analysis: Morphine Overdose, Patient Safety, and Nurse Role

This case study analyzes a nursing incident involving a fatal morphine overdose at an Australian hospital, where a mother received ten times the prescribed dose, leading to a coma and the death of her baby. The study identifies the midwife's negligence in medication administration and the resulting consequences for the patient, her family, and the involved healthcare staff. It emphasizes the importance of adhering to Nursing and Midwifery Board of Australia (NMBA) standards and the National Safety and Quality Health Service Standards to prevent such incidents. The analysis reflects on the critical role of nurses in ensuring patient safety through accurate medication practices, ethical conduct, and continuous professional development. The study concludes by underscoring the need for strict adherence to nursing standards and ethical guidelines to prevent future occurrences and improve patient outcomes. Desklib offers a variety of resources, including past papers and solved assignments, to aid students in their studies.

Case study

TABLE OF CONTENT
INTRODUCTION...........................................................................................................................3
Main body........................................................................................................................................4
Description of nursing incident including nurse role...................................................................4
Identification and explanation of consequences for patient and family.......................................4
Nursing action plan to improve practice for prevention of incident from occurring...................5
Reflection.....................................................................................................................................6
CONCLUSION................................................................................................................................6
REFRENCES...................................................................................................................................6

INTRODUCTION
Nursing And Midwifery Board of Australia (NMBA) registered nurse standards plays
crucial role for outlining specific working requirements for nurses to use best quality medical
practices. National Safety And Quality Health Service Standards adopted by Australian for
safety and quality care in healthcare services, for further improvising practice and reduction of
errors. The report will discuss case study, where mother went to coma discovering baby had died
at birth after she was given 10 times prescribed dose of morphine at hospital in West Australia.
Due to over dosage of morphine, it can be understood that midwife and doctors handling case
were at fault where lady went through coma condition. It further identified that midwife has been
found at error while diagnosing medicine. Research will further bring reflective analysis of
nurses services, where identification of standards importance plays essential role for further
integrated working engagement within nursing services.
Main body
Description of nursing incident including nurse role
The nursing case study signifies focus on aspects where mother experienced
heartbreaking moment where due to over dose of 10 times prescribed dose within morphine at
private hospital within Australia (Raymond, 2020). Nursing incident, has been found due to
negligence while giving morphine to patient where it was found that incident has witnessed
significant decline in patient health. In order to induce pain in mother, nurse had given 10 times
the prescribed dose, where her body reacted to massive overdose of morphine. At intensive care
unit where nurse negligence and avoidance of ethical nursing practices led to coma within
patient. Baby further has been found dead, where excess dosage made situation critical. The
mother experienced huge trauma, where dosage of medicine increased risk on health of both
baby and women. Nurse role is to keep specific focus on monitoring of dosage within medicine
prescription, and also check the limit of prescription.
Identification and explanation of consequences for patient and family
The identification of case study, enables to gain analysis that midwife has been stood
down, where registration suspended and other staff members had resigned within hospital.
Consequences on couple were that they faced depression significantly. Investigation has
signified that department of health and coroner, that it is tragic situation in which case of

negligence by nurse has led to death of baby. Sarah Hassan passed into comma, she after initial
pain she decide to take medication as recommended went wrong. Then within 3 to 5 minutes due
to 10 times morphine she went into coma directly, and baby body was found warm. The incident
had serious impact on family, where father and mother both had tragic situation experienced,
where handling baby in hand, it was unbelievable for both. Later family went into trauma, where
child mortality committee of department within health and corner will further investigate
(Campbell and et.al, 2021). Consequences on nurse was that she was immediately fired, and
whole staff was under legal examination about case severity.
Nursing action plan to improve practice for prevention of incident from occurring
The nursing action plan to improve practice for prevention of incident from occurring in
future can be understood as highly essential aspect, which will enable responding towards
situations with utmost specific care significantly (Tate, 2020). There are 8 NSQH standards,
which cover high prevalence adverse events where healthcare associated infections, medication
safety, comprehensive care, clinical communication and prevention, responding of clinical
deterioration. Standard 1.1 states focus towards understanding of commonwealth, state and law
pertinent to nursing practice where, it aims to further enable nurses to serve treatments with full
accuracy in medication.1.3 is another key element where it demonstrates implications for NMBA
standards, codes and guidelines at workplace for ensuring policies engagement as per nursing
practices. By undertaking this element of standard 1, services will be provided as per specific
guidelines and within prescribed limits for patients (ENROLLED NURSE STANDARDS FOR
PRACTICE, 2016).
Further elements of standards 1.4 and 1.5 regards professional standards and procedural
guidelines for serving patients with full care specifically. Standard 1.8 further ensures safe
outcomes for recognizing need of protect people and risk of potential harms significantly on
wider working horizons. Standard 8 provides nursing care that is well informed and seeks
knowledge for nurses to be guided within varied situations, for improved care and quality
information activities. Incorporating evidence based professional nursing care services will
enable to improve current practice significantly, where further dosage of medicines should be
within prescribed limit. Nurses need to also take significant care of pregnant women, while
prescribing them medicines for taking control of the dosage, and also keeping regulatory

standards in check. Standard 9, aims to evolve practices within safety and quality improvement
guidelines for improvised practices at hospitals and multi-disciplinary contributes to minimize
risk factors significantly.
Reflection
The brief reflection of case study enables to gain knowledge that nurses have specific role
for building ethical treatments and services for patients to be improvised, by serving them with
specific medication as per within prescribed limits (Kaplan-Dobbs and et.al, 2021). Also I further
learnt about significance of nursing standards medical care further plays key role in generating
advanced services. I enhanced my knowledge related to nursing health care standards, that within
the case study, negligence by nurse has harmed mother as well as baby health significantly
where nurses have to be further taken care while prescribing medications. Over dosage of
morphine, where it was 10 times more given than the prescribed limits led to misshapen and
further impacted mother health significantly.
CONCLUSION
From the above analyzed report, it can be concluded that case study has shed light on
analyzing key functional parameters of varied role of nursing practices, where case of morphine
overdose has witnessed significant decline in patient health. The research above also concluded
research presenting detailed focus on massive over dosage within patient, where mother went
into coma due to nurse negligence and avoidance of nursing practices. Research also further
evolved light for in depth explanation on avoidance of NMBA nurse standard for practice
outlines requirements of nurses to use best quality medical practices. Examination of case study
also concluded analysis that there is further significant knowledge, beliefs and professional
nursing skills which should be followed by nurses ethically.

REFRENCES
Books and Journals
Campbell, J., and et.al, (2021). Pregnancy-associated deaths from homicide, suicide, and drug
overdose: Review of research and the intersection with intimate partner
violence. Journal of Women's Health. 30(2). 236-244.
Kaplan-Dobbs, M and et.al, (2021). Increasing Access to Buprenorphine in Safety-Net Primary
Care Clinics: The New York City Buprenorphine Nurse Care Manager
Initiative. American Journal of Public Health. 111(2). 215-218.
Raymond, S. (2020). Implementation and recommendations of safe injection sites to reduce the
number of opioid related overdose deaths.
Tate, A. K. (2020). Strategies to Optimize Control of Opioid Overdose in the Hospital &
Community Settings.
Online
ENROLLED NURSE STANDARDS FOR PRACTICE. 2016. [Online]. Available Through :<
file:///C:/Users/user/Downloads/Nursing-and-Midwifery-Board---Standards-for-
Practice---Enrolled-Nurses.PDF>