mary was an excellent nurse with 10 years’ experience in obstetrics. on this particular day, she was sitting across the desk from the nursing supervisor, tears rolling down her cheeks. "i don’t know how it could have happened," she said. a pregnant woman who had come to the hospital healthy, with a healthy fetus and an uneventful pregnancy, had suddenly stopped breathing and appeared unresponsive and paralyzed.when the patient’s status began to deteriorate rapidly, mary called the code team and started mouth-to-mouth resuscitation. the code team was able to stabilize the mother and fetus, but they were perplexed by the situation. it was at this time that mary recognized her error: she had opened the wrong iv and administered the wrong medication to the patient — magnesium instead of saline was running at maximum rate. imagine that you are mary’s nursing supervisor. what concerns might you have about mary?
