| Course | NU653 AGACNP Acute Care Diagnosis and Management Clinical II |
|---|---|
| Unit | Unit 7 |
| Paper type | Case conference review |
| Length | About 1,100 words, 6 pages double-spaced |
| Format | APA 7 student paper |
| School | Purdue University Global |
| Program | MSN |
| Updated | September 2026 |
Free sample paper for NU653 Unit 7
Five Slices and a Question at 21:00: A Case Conference Review of Treatment-Dose Enoxaparin Continued After a Negative Duplex
[Student Name]
Purdue University Global
NU653: AGACNP Acute Care Diagnosis and Management Clinical II
Unit 7 Case Conference Review
[Instructor Name]
[Date]
The patient and all staff are composite and identified by role; times and doses are bracketed.
Summary
Mrs. [S.], a [73]-year-old woman with osteoarthritis of both knees, was admitted on [Day 0] with a swollen, painful right calf. Deep vein thrombosis was presumed, and treatment-dose enoxaparin, [1 mg/kg] every [12] hours, was started in the emergency department. On [Day 1] at [11:40], a duplex ultrasound showed no thrombosis and a ruptured Baker cyst behind the right knee. The afternoon progress note recorded the revised diagnosis correctly. The enoxaparin order was not stopped. At [21:00], her nurse questioned the dose, paged the covering clinician and the dose was held. No harm occurred, but she had received [one] dose after the duplex that she did not need.
Timeline
1. [11:40]. Duplex result posted: no deep vein thrombosis; ruptured Baker cyst.
2. [12:15]. Day team reviews the result on rounds; plan stated aloud to stop enoxaparin.
3. [13:30]. Progress note written: "DVT ruled out, ruptured Baker cyst; supportive care." No order change entered.
4. [14:00]. Scheduled enoxaparin dose due; given by the day nurse from the active order.
5. [16:45]. Pharmacist review of the day's new orders; no new anticoagulant order, so no review triggered.
6. [17:30]. Written handoff document updated from the morning version; problem list still reads "RLE DVT on enoxaparin."
7. [17:45]. Verbal handoff to the night clinician; enoxaparin not mentioned.
8. [20:50]. Night nurse reads the day's progress note while preparing the dose.
9. [21:00]. Nurse calls the covering clinician; dose held; order discontinued at [21:10].
The Model
Reason's Swiss cheese model describes safety as a series of defensive layers, each with holes, and explains an accident as a path that finds a gap in every layer at once (Reason, 2000). The model is useful here because no single person made a wrong decision. The diagnosis was revised correctly. The problem was that the revision did not travel through the system.
The Five Slices
Slice one: the prescriber's reasoning. The duplex result was read, interpreted correctly and written into the note. But the diagnosis was closed without closing its treatment. Revising a diagnosis in a note does not change an order, and the medication record acts on orders, not on notes. The hole in this slice was the gap between the plan stated on rounds and the order screen.
Slice two: the order system. The enoxaparin order carried no linked indication. Had it required one, such as deep vein thrombosis, a revised problem list could have prompted review of the order. Requiring an indication for certain medications has been shown to intercept some prescribing errors in computerized order entry, such as orders placed for the wrong patient (Galanter et al., 2013), and the same design could flag an order whose indication has been removed.
Slice three: pharmacist verification. Pharmacists review new orders. No new order was placed, so the existing order passed unreviewed. The hole was a design that looks at changes and not at orders whose reason has disappeared.
Slice four: the handoff. The written handoff was updated by editing the morning version, and the problem list line carried forward unchanged. The verbal handoff did not mention the anticoagulant. Structured handoffs that include an action list reduced medical errors in a multicenter study (Starmer et al., 2014); here, stopping the enoxaparin was an action that belonged on that list and never reached it.
Slice five: the nurse. The night nurse read the progress note before giving a high-alert medication, noticed that the note and the order disagreed, and called. This slice held. The review records it as a strength of the system, not as luck.
Why the Near Miss Matters
It is tempting to treat an event that caused no harm as a minor matter, and near misses are often not reported for that reason. This one deserves a full review for three reasons. First, the hazard was real: treatment-dose enoxaparin in a [73]-year-old woman carries a bleeding risk that is acceptable only when there is a clot to treat. Second, the holes that let it through are not specific to this patient; any revised diagnosis on this unit could leave a dependent order behind in the same way. Third, the event was stopped by a single person using judgment, which means the next one may not be. A system that relies on one nurse reading one note before one dose has one layer of defense, not five.
The review also looked at why the day nurse gave the [14:00] dose. She had not been on rounds, the order was active, and the progress note was not yet signed when the dose was due. Her action was correct given what she could see. That is the point of the model: the same act can be safe or unsafe depending on the layers around it.
Contributing Factors
1. Timing: the result arrived during rounds, when the plan was spoken but not entered.
2. Workload: the day team had [16] patients and [four] admissions.
3. Design: no system link between a revised diagnosis and the orders that depend on it.
4. Culture: the stated plan on rounds was treated as done.
Recommendations
1. Prescriber: when a diagnosis is revised in a note, the same session should include a review of every order that depends on it, and the note template will carry a line: "orders reviewed for revised diagnosis."
2. Order system: require an indication for treatment-dose anticoagulants, and prompt review when that indication is removed from the problem list.
3. Pharmacy: add a daily review of active anticoagulant orders against the problem list, not only new orders.
4. Handoff: regenerate the written handoff from the current problem list each afternoon rather than editing the morning copy, and include anticoagulants in every verbal handoff.
5. Nursing: recognize the night nurse's check formally, and teach it as a standard step: read the latest note before any high-alert dose.
Discussion at the Conference
The group agreed that the most useful fix is the one that does not depend on memory: linking the anticoagulant order to its indication. The other changes reduce the size of each hole, but a structural link closes one. The group also agreed that the patient should be told what happened, and she was, on [Day 2], by the attending.
References
Galanter, W., Falck, S., Burns, M., Laragh, M., & Lambert, B. L. (2013). Indication-based prescribing prevents wrong-patient medication errors in computerized provider order entry (CPOE). Journal of the American Medical Informatics Association, 20(3), 477-481. https://doi.org/10.1136/amiajnl-2012-001555
Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768-770. https://doi.org/10.1136/bmj.320.7237.768
Starmer, A. J., Spector, N. D., Srivastava, R., West, D. C., Rosenbluth, G., Allen, A. D., Noble, E. L., Tse, L. L., Dalal, A. K., Keohane, C. A., Lipsitz, S. R., Rothschild, J. M., Wien, M. F., Yoon, C. S., Zigmont, K. R., Wilson, K. M., O'Toole, J. K., Solan, L. G., Aylor, M., . . . Landrigan, C. P. (2014). Changes in medical errors after implementation of a handoff program. New England Journal of Medicine, 371(19), 1803-1812. https://doi.org/10.1056/NEJMsa1405556
What the NU653 Unit 7 assignment asks for
The Unit 7 assignment asks you to prepare a case conference review of an adverse event or near miss, written as a handout for a multidisciplinary meeting. You summarize the event, build a timeline, apply a safety model to explain how the event happened, identify contributing factors, credit what went right and make recommendations for each layer of the system. Staff should be identified by role only. Most prompts set five pages. The review should analyze how defenses failed rather than who made a mistake, and near misses deserve the same analysis as events that caused harm. Credit what worked, too, since a near miss was stopped by something worth protecting.
Inside the NU653 Unit 7 example
The example opens with a summary that states the outcome, a dose stopped with no harm. The timeline records what was known and done at each time, from the duplex result to the nurse's call. Reason's model is explained in a sentence and then applied to five slices, each described by what it was supposed to catch and why it did not. The order-system slice cites research on indication prompts, and the handoff slice cites the I-PASS study. A section explains why a near miss deserves full review. Contributing factors, recommendations matched to slices and the conference discussion complete the handout. Its final section records what the group agreed and whether the patient was told.
NU653 Unit 7 rubric: what earns full points
In the Unit 7 rubric, points go to a precise timeline, a safety model that is actually applied, a fair account of contributing factors, targeted recommendations and a tone free of blame. The timeline earns full credit when it is precise and neutral. The model counts when it is applied to specific points in the case, not just described. Contributing factors should include system and human elements. Recommendations are judged on whether each addresses an identified gap, and on whether some are structural rather than reminders. Tone matters: identifying staff by role and avoiding blame are expected. Graders also look for a clear statement that the patient was told.
Common NU653 Unit 7 mistakes, and how to avoid them
A common mistake is writing the review as a search for the person at fault. Another is naming a model without applying it to the case. Students often recommend education alone, which relies on memory and closes no holes. Near misses are sometimes treated as minor because no harm occurred. The layer that worked, here the nurse, is often left out. And timelines are frequently written with hindsight, recording what was later learned rather than what each person knew at the time. A review that ends with a single structural fix, agreed by the group, is more likely to change practice than a long list of reminders. Also check that the timeline times match across every section.
Get an NU653 Unit 7 example written to your instructions
Some programs want a one-page conference handout, others a full root cause write-up, and a few assign a specific framework. Describe the composite event, say which framework is assigned, if any, and attach the rubric. A first review, at no cost and ready in 24-48h, analyzes every layer and credits the one that held. The paper above is an original model document written by our desk, not a submitted student paper and not an official Purdue University Global document.
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NU653 Unit 7 questions, answered
Can the review be based on an event from my rotation?
The pattern of an event can inform a composite, but anything pointing to a real patient, colleague or unit must be altered, and your site may have rules about discussing safety events outside its own review process. The sample is entirely invented. Any report you filed, or any review your site conducted, stays within that site's process and is not reproduced.
Why include what went right in a near-miss review?
Because a near miss is stopped by something, and that something is worth protecting. Safety programs increasingly study successful defenses as well as failures. The sample gives the nurse's question its own section, describing the behavior and the conditions that allowed it, such as readable notes and a unit culture that welcomes challenges.
Is the Swiss cheese model still accepted?
It remains widely taught, though critics note that it can make defenses look independent and static when they actually interact. The sample acknowledges that limitation in a sentence and uses the model for what it does well, showing how several partial failures line up. If your course prefers a systems framework such as SEIPS, the review can be built on that instead.
Where can I find a free NU653 Unit 7 sample paper?
The complete NU653 Unit 7 case conference review is on this page, with the timeline, five slices of the Swiss cheese model, contributing factors and recommendations. A free review of a different event can be written from your case.
Why include what went right in the NU653 Unit 7 review?
Because the near miss was stopped by a nurse who read the note before giving a high-alert drug. Recording that step as a strength protects it and makes it something the unit can teach, rather than leaving it to chance.