Question

Case Study

Phyllis, 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. Phyllis’ 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 among the elderly, and started her on an iron

supplement during hospitalization. He also ordered a stool for occult blood because anemia can

be caused by GI bleeding from ulcers and other illnesses.

Phyllis’ neurologic condition rapidly improved with anticoagulant treatment and physical

therapy and she was discharged home three days after admission. The stool for occult blood

test was never done by the hospital staff and went unnoticed by the discharging physician, who

was different from the hospitalist who had admitted her. One of the discharge instructions from

the RN for Phyllis, in addition to the use and side effects of anticoagulants taken at home, a high

iron diet and iron supplements, was to contact her primary care provider for follow-up to

determine the cause of the anemia. The discharging physician did not schedule an appointment

with the primary care provider.

Ten days after discharge, Phyllis was admitted to the ER with severe abdominal pain,

low blood pressure and a weak thread pulse. After an MRI of the abdomen, she was diagnosed

with a ruptured intestinal diverticulum and major interabdominal 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

Phyllis if 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 if her

speech and weakness were improved. After replying “yes,” the office clerk told Phyllis that all

she needed to do was to keep her next routinely scheduled appointment in two months. The

records from the recent hospitalization had not been reviewed by anyone at the office, and the

primary care provider was not aware of the patient’s anemia that had been identified in the

hospital.

Answer the questions and a case study summary in the end.

Questions

• As with most patient errors, there was a chain of events that led up to the final result.

List the chain of events involved with the client’s case.

• Who was primarily responsible for causing the poor outcome in this case?

• If an RN Patient Safety Officer was reviewing this case, what sentinel events would he or

she identify as needing risk reduction policies?

• What would you do to correct the events that lead to the poor outcome for Phyllis?

• What are the ethical issues involved in this case?

Answer 1

1.Here the chain of the events that lead to the patient/ medical error are the following:

a. The stool for occult blood test was never done by the hospital staff.

b. The discharging physician was different from the hospitalist who admitted her.

c. The discharging physician did not schedule an appointment with the primary care provider.

d. Nobody in the primary care providers office reviewed her records of recent hospitalization and primary care provider was unaware of her anemia.

2. The responsibility of the poor outcome in this case lies on heath care providers as whole. Communication breakdown(both verbal and written), inadequate information flow, and human problems etc resulted in the poor outcome of the patient.

3.Many patient risks can be reduced by adequately training physicians and other staffs, encouraging strong communication among staff members, proper documentation, ensuring adequate flow of information between different health settings, patient education and counselling.

4. If I was the care provider, I would have done the stool test for occult blood in the first place, to rule out any possible internal GI bleed. Also I would have ensured a proper follow up for this patient in order to avoid any future complications.

5.The ethical issues related to medical errors can be categorised around 4 ethical principals. Autonomy and right to self determination, beneficence and nonmaleficence, disclosure and right to knowledge, veracity.

Autonomy and right to self determination : this concept acknowledges patients' right to make their choices and to take action based on their views and perceived benefits.

Beneficence and non malefiecence : this directs health care providers to deliver what is best for the patients and to avoid harm.

Disclosure and right to knowledge : health care providers have a ethical obligation to disclose information to the patients so that they can do informed decision making.

Veracity: the principle of veracity requires health care personnel to provide comprehensive and accurate information in a manner that helps the patients to understand the information. Telling the truth about the medical errors helps to establish trust.