Problem:
Ms. Chang, a nurse at a nursing facility, is working an extended shift because the nurse who was to relieve her recently quit and no one else was available to come in. Exhausted, Ms. Chang continues to make her rounds, stopping and administering a scheduled injection of insulin to a resident, Mr. Patel, with diabetes. As she is completing this task, a resident cries out from down the hall, and she hurries to her room to tend to her. After cleaning up the incontinent resident-the nursing assistant had called in sick-Ms. Chang proceeds to retrace her steps and picks up her rounds where she left off. Remembering that she had been in Mr. Patel's room last, she returns and proceeds to administer an insulin injection to him. She continues her round. Later, she hears a commotion coming from Mr. Patel's room and, returning, finds the charge nurse leaning over him and calling his name. Mr. Patel was nonresponsive. "Grab some orange juice from the food cart!" she said. "His blood sugar is too low." In time, Mr. Patel recovers. Ms. Chang, however, is devastated when she realizes what she's done. She reports it to her supervisor and writes up an