Case Study Now let’s continue with the story ...of “An Extended Stay” The ultrasound, unfortunately, confirmed the pre
Posted: Mon Apr 04, 2022 6:43 am
Case Study
Now let’s continue with the story ...of “An Extended
Stay”
The ultrasound, unfortunately, confirmed the presence of a blood
clot in Mr. Londborg’s
left calf. Due to his impaired kidney function, treatment for the
blood clot required him to
remain in the hospital on IV medication.
Mr. Londborg’s stay was going to be longer than expected.
At 10 PM on his eighth day in the hospital, a member of the
environmental services
(also known as housekeeping) staff found Mr. Londborg on the floor
of his room. She
immediately alerted the nurses on the ward. The nurses noted
seizure activity and
called the overnight medical team to Mr. Londborg’s bedside. The
team responded
quickly and gave him intravenous medication that stopped his
seizure.
Because no one witnessed his fall and seizure, Mr. Londborg
underwent an emergent
CT scan of his head to check for any sign of bleeding. After his
mental status improved
(it is common for patients to be confused for a time after a
seizure), he complained of
pain in his left shoulder and elbow, but x-rays of these joints
showed no evidence of a
traumatic fracture from his fall.
After ensuring that Mr. Londborg was stable, the overnight care
team reviewed the chart
and the medication history to try to determine the cause of Mr.
Londborg’s sudden
seizure. They found that one of his seizure medications,
levetiracetam, had not been
given earlier in the day when it should have been. There was a
notation in the
medication administration record from the daytime nurse indicating
that the ordered
dose was not available in the automatic medication dispensing
system on the floor
earlier in the day.
Further discussions the following day with the daily care team of
doctors and nurses
revealed that the nurses didn’t notify the physicians or the
pharmacy that the essential
medication was not administered. The medication system didn’t
include an automatic
alert, either.
Fortunately, the overnight physicians restarted Mr. Londborg on his
medication, and he
suffered no apparent permanent harm. Mr. Londborg was discharged
after 10 days in
the hospital. Most hospitalizations for COPD are far shorter. In
fact, many last only a
couple days.
Page 1 of 2
Case Study
Discussion Questions:
1) Unfortunately, Mr. Londborg suffered a seizure, a complication
that could likely have
been avoided if he had received all of the ordered anti-seizure
medications. Identify at
least two specific errors that contributed to this mistake.
2) Based on the types of errors you just identified, can you
identify systems
issues/failures that affected Mr. Londborg’s hospitalization?
3) Identify at least one thing that went well during Mr. Londborg’s
visit to the hospital.
4) How would you run a meeting to debrief team members in the days
after Mr.
Londborg’s seizure?
Now let’s continue with the story ...of “An Extended
Stay”
The ultrasound, unfortunately, confirmed the presence of a blood
clot in Mr. Londborg’s
left calf. Due to his impaired kidney function, treatment for the
blood clot required him to
remain in the hospital on IV medication.
Mr. Londborg’s stay was going to be longer than expected.
At 10 PM on his eighth day in the hospital, a member of the
environmental services
(also known as housekeeping) staff found Mr. Londborg on the floor
of his room. She
immediately alerted the nurses on the ward. The nurses noted
seizure activity and
called the overnight medical team to Mr. Londborg’s bedside. The
team responded
quickly and gave him intravenous medication that stopped his
seizure.
Because no one witnessed his fall and seizure, Mr. Londborg
underwent an emergent
CT scan of his head to check for any sign of bleeding. After his
mental status improved
(it is common for patients to be confused for a time after a
seizure), he complained of
pain in his left shoulder and elbow, but x-rays of these joints
showed no evidence of a
traumatic fracture from his fall.
After ensuring that Mr. Londborg was stable, the overnight care
team reviewed the chart
and the medication history to try to determine the cause of Mr.
Londborg’s sudden
seizure. They found that one of his seizure medications,
levetiracetam, had not been
given earlier in the day when it should have been. There was a
notation in the
medication administration record from the daytime nurse indicating
that the ordered
dose was not available in the automatic medication dispensing
system on the floor
earlier in the day.
Further discussions the following day with the daily care team of
doctors and nurses
revealed that the nurses didn’t notify the physicians or the
pharmacy that the essential
medication was not administered. The medication system didn’t
include an automatic
alert, either.
Fortunately, the overnight physicians restarted Mr. Londborg on his
medication, and he
suffered no apparent permanent harm. Mr. Londborg was discharged
after 10 days in
the hospital. Most hospitalizations for COPD are far shorter. In
fact, many last only a
couple days.
Page 1 of 2
Case Study
Discussion Questions:
1) Unfortunately, Mr. Londborg suffered a seizure, a complication
that could likely have
been avoided if he had received all of the ordered anti-seizure
medications. Identify at
least two specific errors that contributed to this mistake.
2) Based on the types of errors you just identified, can you
identify systems
issues/failures that affected Mr. Londborg’s hospitalization?
3) Identify at least one thing that went well during Mr. Londborg’s
visit to the hospital.
4) How would you run a meeting to debrief team members in the days
after Mr.
Londborg’s seizure?