Sentinel event and communication
A 72-year-old woman who developed slurred speech and weakness in her right arm and hand was referred from her primary care provider’s office to a hospitalist for admission and evaluation of a possible TIA. Her admitting physical evaluation by the RN showed an elderly but otherwise generally healthy patient. The admission lab tests were all within normal limits except for her CBC, which showed a moderate degree of anemia. The hospitalist attributed this to a diet low in iron, which is not unusual in the elderly, and started her on an iron supplement during hospitalization. He also ordered a stool test for occult blood because anemia can result from GI bleeding caused by ulcers and other illnesses.
Her neurological condition rapidly improved with anticoagulant treatment and physical therapy, and she was discharged home three days after admission. The hospital staff never did the stool for an occult blood test, and this omission went unnoticed by the discharging physician, who was not the hospitalist who had admitted her. The discharge instructions from the RN were to use the prescribed anticoagulants, a diet high in iron, and iron supplements, and to contact her primary care provider for a follow-up to determine the cause of the anemia. Unfortunately, the discharging physician did not schedule an appointment with the primary care provider.
Ten days after discharge, she was admitted to the ER with severe abdominal pain, low blood pressure, and a weak, thready pulse. After an MRI of her abdomen, she was diagnosed with a ruptured intestinal diverticulum and major intra-abdominal bleeding. She was immediately taken to surgery, where a section of her large intestine was resected, and a colostomy was performed.
After reviewing her chart from her previous admission, her primary care RN asked her whether she had seen her primary care provider for the follow-up on the anemia, which may have detected the impending GI bleed and reduced the severity of the surgery. The client responded that she had called about an appointment, and the office clerk had asked her whether her speech and weakness were improved. After she responded, “Yes,” the office clerk told her that all she needed to do was to keep her next routinely scheduled appointment in two months. No one had reviewed the records from the recent hospitalization at the office. The primary care provider was not aware of the patient’s anemia identified in the hospital.
DISCUSSION PROMPTS
- As with most patient errors, there was a chain of events that led up to the result. List the chain of events involved with the client’s case.
- Who or what was primarily responsible for causing the poor outcome in this case? Why do you believe this individual, or entity was primarily responsible?
- What sentinel events would have been identified as needing risk-reduction policies?
- What would you do to correct the events that led to the poor outcome?
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