| Course | NURS 6380 Advanced Pathopharmacology and Health Assessment for Nurse Educators |
|---|---|
| Week | Week 10 |
| Paper type | Medication error analysis |
| Length | About 1,020 words, 6 pages |
| Format | APA 7 student paper |
| School | Walden University |
| Program | Master of Science in Nursing (MSN) |
| Updated | September 2026 |
Free sample paper for NURS 6380 Week 10
The Epidural Bag on the Wrong Line: A High-Alert Medication Error Analysis of Local Anesthetic Toxicity After a Thoracotomy, Written for Learners to Work Through
Student Name
College of Nursing, Walden University
NURS 6380: Advanced Pathopharmacology and Health Assessment for Nurse Educators
Instructor Name
Month Day, Year
The Epidural Bag on the Wrong Line: A High-Alert Medication Error Analysis of Local Anesthetic Toxicity After a Thoracotomy, Written for Learners to Work Through
The Case
Mrs. Duarte, 64, is on a surgical unit on the first day after a right thoracotomy for a lung resection. She has a thoracic epidural infusion of bupivacaine with fentanyl for pain, running on a dedicated pump, and a peripheral intravenous line for antibiotics and maintenance fluid on a second pump. Both lines use clear tubing, and the two pumps sit side by side on the same pole. The case is a composite created for teaching; every person and time in it is fictional.
At 1850, during a busy change of shift, the epidural bag alarms empty. The day nurse, finishing a discharge, asks a float nurse to hang the new epidural bag from the medication room. The float nurse spikes the new bag and connects its tubing to the nearest available port, a needleless connector on the peripheral intravenous line, then programs the epidural pump at the ordered rate. The day nurse gives report at 1905 at the station rather than in the room, so neither nurse looks at the lines.
At 1940, Mrs. Duarte tells the night nurse that her lips feel numb and she has a metallic taste; the nurse attributes it to her anti-nausea medication. At 2010 she says her ears are ringing and she seems restless and talkative. At 2030 her daughter calls the nurse because her mother is confused and twitching around the mouth. At 2034 she has a generalized seizure. The rapid response team finds the epidural bag connected to the intravenous line.
Part 1: Pharmacology
Bupivacaine is a local anesthetic that blocks sodium channels in nerve membranes, which stops nerve impulses and relieves pain when it is delivered around the spinal nerves. In the epidural space, it is absorbed slowly and in small amounts. Delivered into a vein, the same drug reaches the brain and heart directly, where sodium channel blockade disturbs normal electrical activity. Toxicity typically shows first in the central nervous system, with numbness around the mouth, a metallic taste, ringing in the ears, agitation and confusion, then muscle twitching and seizures, followed by depression of consciousness and breathing. Cardiovascular effects, including slowed conduction, arrhythmias and low blood pressure, may follow or occur at the same time, and bupivacaine is known for severe cardiac toxicity (Burchum & Rosenthal, 2022).
The recognized response is local anesthetic systemic toxicity management: stop the infusion, call for help, manage the airway, control seizures with a benzodiazepine, and give lipid emulsion, which binds local anesthetic and supports the heart, with advanced life support modified for this situation. The current practice advisory notes that recent cases more often present late and involve continuous infusions, and that a growing share of events occur outside operating rooms and involve clinicians other than anesthesiologists (Neal et al., 2018). That is the setting of this case.
Part 2: Assessment Cues, Hour by Hour
Learners work through the timeline and answer, for each time point, what the cue meant and what should have happened. At 1940, perioral numbness and metallic taste are early signs of central nervous system toxicity; the right response was to consider the drugs the patient was receiving, trace every line to its source and report. At 2010, ringing in the ears and restlessness should have prompted stopping any local anesthetic infusion and calling the provider. At 2030, confusion and perioral twitching called for an immediate rapid response. Learners are asked which cue should have prompted escalation, and why the first one was explained away, a pattern sometimes called anchoring on an easier explanation.
Part 3: System Analysis
The Swiss cheese model describes serious errors as the result of several defenses failing at once, each with its own hole, rather than of one person's failure (Reason, 2000). Learners identify at least five holes that lined up here. Tubing: the epidural tubing was clear and identical to intravenous tubing, with no yellow striping or label. Connector: the epidural tubing had a standard connector that fit an intravenous port; connectors designed so that neuraxial tubing cannot connect to intravenous devices would have stopped the error physically. Staffing: a float nurse unfamiliar with the unit hung a high-alert infusion during a busy handoff. Handoff: report at the station meant nobody traced the lines from bag to patient. Pumps: two similar pumps side by side, neither labeled with its route. Knowledge: the night nurse did not connect early symptoms to a local anesthetic.
Learners then discuss accountability. The float nurse made a slip, and the analysis names it plainly, but a just culture approach asks whether the system made the slip likely and whether the behavior was an error, a risk taken without recognizing it, or a reckless choice. Most learners conclude that the most effective fixes are the physical ones, incompatible connectors and route-labeled tubing and pumps, backed by bedside handoff with line tracing, rather than a reminder to be careful.
Part 4: Teaching Section
Learner objectives: learners will (1) explain how the route of a local anesthetic changes its effects, (2) recognize the early signs of local anesthetic systemic toxicity, and (3) identify system defenses that prevent route errors with high-alert infusions. Epidural medications are named among the high-alert drugs that ISMP identifies for hospitals, and learners should look through that list to find which other drug classes carry a similar risk when given by the wrong route or at the wrong rate (Institute for Safe Medication Practices [ISMP], 2024).
Discussion questions: What would you do at 1940 if you were the night nurse? Why did the drug cause symptoms in the brain before the heart? Which of the five system holes would you close first, and what would it cost? How would bedside handoff with line tracing have changed the timeline? What would you say to the float nurse the next day? Finally, learners draft the two-sentence message the unit educator would send to all staff the following morning, stating what happened without naming anyone and what will change.
References
Burchum, J. R., & Rosenthal, L. D. (2022). Lehne's pharmacology for nursing care (11th ed.). Elsevier.
Institute for Safe Medication Practices. (2024). ISMP list of high-alert medications in acute care settings.
Neal, J. M., Barrington, M. J., Fettiplace, M. R., Gitman, M., Memtsoudis, S. G., Mörwald, E. E., Rubin, D. S., & Weinberg, G. (2018). The third American Society of Regional Anesthesia and Pain Medicine practice advisory on local anesthetic systemic toxicity: Executive summary 2017. Regional Anesthesia and Pain Medicine, 43(2), 113-123. https://doi.org/10.1097/AAP.0000000000000720
Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768-770. https://doi.org/10.1136/bmj.320.7237.768
The Walden NURS 6380 Week 10 instructions
Week 10 prompts commonly have you analyze a medication error involving a high-alert drug for use in teaching, covering the pharmacology of the drug, the assessment cues that were missed, the system factors that contributed and teaching strategies for learners. Many prompts name a safety model such as the Swiss cheese model or just culture. The analysis is usually three to five pages. If you use an event from practice, remove every identifying detail and follow your organization's rules. If you create a case, make the timeline realistic enough that learners can reason through it hour by hour. Some prompts also ask for a brief summary written for staff, separate from the teaching analysis.
Inside the NURS 6380 Week 10 example
The case section describes the setting, the two pumps, the error during handoff and the timeline from 1940 to 2034. Part 1 explains sodium channel blockade, why toxicity appears in the brain before the heart and the recognized response including lipid emulsion, citing the practice advisory's note that recent cases involve continuous infusions. Part 2 walks through each time point and what should have happened. Part 3 applies the Swiss cheese model to tubing, connectors, staffing, handoff, pumps and knowledge, then discusses accountability using just culture. Part 4 gives objectives, the ISMP list and six discussion questions.
Where the marks sit in the NURS 6380 Week 10 rubric
Error analysis rubrics usually score accuracy of the pharmacology, identification of assessment cues, system analysis, use of a safety framework, the teaching plan and evidence. Pharmacology must explain why the error caused the specific effects seen. Cue identification is judged on timing, so noticing that the first sign was explained away earns credit. System analysis rewards several contributing factors, not a single blamed person. Framework use should shape the analysis rather than be named at the end. The teaching plan is scored on objectives and questions another educator could use. Graders also look for an accountability discussion that neither blames one nurse nor excuses everyone, which a just culture lens provides.
Common NURS 6380 Week 10 mistakes, and how to avoid them
The most frequent mistake is an analysis that ends with retraining the nurse involved, which ignores why the error was possible. Another is pharmacology copied from a drug guide without linking it to the patient's symptoms. Some analyses list system factors without saying which fix would work best. Others use a real event with details that could identify people. Build a realistic timeline, explain each symptom through the mechanism, find at least five holes in the system, rank the fixes and give learners questions that make them decide what they would do. Keep the case narrative neutral in tone; judgment belongs in the analysis, not in how the timeline is told. Check each drug fact against a current pharmacology reference before it goes into a case learners will study.
Get a NURS 6380 Week 10 example written to your instructions
A different high-alert medication, insulin, an opioid or a potassium concentrate, can anchor the analysis if your prompt names one; send it with the rubric and prompt wording. The Week 10 analysis arrives within 24 to 48 hours and the first custom one is free. The infusion error here is invented, and no incident report was used.
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NURS 6380 Week 10 questions, answered
Why does the analysis avoid blaming the nurse who hung the bag?
It does not avoid accountability; it places it in context. The Swiss cheese model shows that one person's slip reached the patient only because other defenses also failed. Many nursing programs also teach just culture, which distinguishes human error from at-risk and reckless behavior. The analysis names the slip and then examines why the system allowed it to matter.
Could learners use this case in a classroom?
The teaching section is designed for that, with objectives and discussion questions an educator could use directly. Any sample should be checked against your program's pharmacology references and your institution's policies before it reaches learners, since details differ. For your own submission, the case and the analysis should be written by you, with the example serving as a standard.
Where can I find a free NURS 6380 Week 10 sample paper?
The complete error analysis, including the case, all four parts and the discussion questions, can be read here without charge. A custom analysis of another high-alert drug can be written by the desk free of charge.
Is the epidural error in the NURS 6380 example a real event?
No. The patient, the staff and every time in the case are invented, though route errors of this kind are described in safety literature. If you analyze an event from your workplace, remove every identifying detail.
Why an epidural error rather than an anticoagulant error?
Anticoagulant errors are well covered in teaching materials, while route errors with local anesthetics teach something different: how the same drug becomes dangerous by a different route, and why physical defenses such as incompatible connectors work better than reminders.