Question

Use the answer sheet provided for the project to identify which (if any) of the events or sitautions described happened in each cases.

Use our report template to create a report for the medical staff review committee. Under conclusion discuss one process change that can be implemented to reduce risk exposure and provide at least two ways in which change can be managed smoothly when implementing the new process.  

Presume you are a data analyst in the hospital health information management department. One of your job responsibilities is to review records of discharged patients to determine if specific events or situations (known as occurrences) took place during the patient's hospital stay. If one or more of the occurrences took place, the case will undergo peer review by members of the medical staff professional practice committee. This committee has requested that you notify it of cases in which one or more of the following events or situations occurred during the patient's hospital stay. Take note of the numbers corresponding to each occurrence. You'll use them later to complete the project.
01 Cardiac and/or pulmonary arrest, resuscitation successful
02 Cardiac and/or pulmonary arrest, resuscitation unsuccessful
03 Cardiac and/or pulmonary arrest, not resuscitated, recovered
04 Cardiac and/or pulmonary arrest, not resuscitated, expired
05 Readmission within 30 days for same/similar diagnosis
06 Unplanned admission following outpatient procedure
07 Unplanned return to the operating room
08 Unexpected neurological deficit developed after invasive procedure
09 Renal and/or cardiovascular complications following invasive procedure
10 Reintubation within 24 hours of anesthesia
11 No definitive diagnosis within 72 hours of admission
12 Pathological diagnosis does not match preoperative diagnosis
13 Reports or tests misread or misidentified
14 Extended post-anesthesia recovery unit stay (more than 3 hours)
15 Unplanned transfer to cardiac care unit (CCU) or intensive care unit (ICU)
16 Patient suicide-attempted or successful
17 Admission evening prior to elective surgery without appropriate indications
18 Medication error or adverse drug event resulting in patient injury
19 Patient fall resulting in patient injury
20 Patient discharged "against medical advice"
21 Unplanned removal, injury or repair of an organ or structure during invasive procedure
22 Nosocomial infection
23 Blood transfusion reaction

For each case, indicate the event or situations that occurred by recording the number to the left of the occurrence description (as shown in the workbook). If more than one occurrence happened in a case, record all the relevant occurrence numbers in the space provided. If none of the occurrences happened during a particular case, record 0 (zero).

Case	Occurrence Number(s)
#1

Case # 1 An 8-year-old male was seen in the pediatric outpatient clinic on 6/23 complaining of acute abdominal pain. Physical examination and blood tests suggested the patient may have an acute appendicitis and he was immediately transported to your hospital. Upon admission, the patient underwent a C-T scan of the abdomen but it did not show an acute appendicitis. The patient was started on IV antibiotics but his condition failed to improve. The next day, on 6/24 he was taken to surgery with the preoperative diagnosis of "probable acute appendicitis." An appendectomy was performed. The patient's post- operative course was uneventful and he was discharged on 6/25. Pathological examination of the appendix revealed no inflammation. The patient's final diagnosis, as documented by the surgeon, was "acute bacterial gastroenteritis."

Case # 2 On 4/11, a 68-year-old male patient was admitted to the intensive care unit at your hospital with diagnoses that included congestive heart failure, non-insulin dependent diabetes, edema of the lower extremities with cellulitis, ulcer of his toe, hypertension and bladder outlet obstruction. On 4/13 underwent a non-invasive vascular study procedure. Following the procedure, the patient suffered a cardiac arrest. Caregivers started cardiopulmonary resuscitation immediately however the resuscitation attempts failed. The attending physician documented that the patient's death was due to complications of severe congestive heart failure secondary to cardiovascular disease.

Case # 3 On 6/15, a 53-year-old female was admitted to your hospital for surgical repair of a broken left fibula, sustained at home when she fell out of her wheelchair. Her medical history included diabetes, chronic kidney failure, thyroid and pulmonary problems. She had the surgery on 6/16 and was given two units of blood during surgery. Postoperatively she had problems with hyperglycemia. The patient's condition eventually stabilized and she was discharged a skilled nursing facility for continued physical therapy on 6/27.

Case # 4 On 3/23 a 32-year old female underwent a planned C-section at your hospital. She also had a tubal ligation at the same time. For several weeks after the procedure she had GI complaints and chronic diarrhea and was seen by her primary care physician and a gastroenterologist. Two months after her C- Section she presented to your hospital emergency department with acute abdominal pain, thought due to a bowel obstruction. CT scan at that time showed a retained sponge from her previous C-section and tubal ligation surgery. During her second hospitalization she underwent surgery for removal of the sponge and repair of a perforated bowel.

Case # 5 On 6/24, a 70-year old woman was admitted to the medical unit of your hospital following an extensive stroke that left her with a swallowing disorder. On admission a soft, small-diameter (10 French) nasogastric feeding tube was inserted into the patient's stomach by her physician. The correct location of the tube was confirmed by auscultation. Two hours after admission, a nurse gave the patient a pint of enteral feeding supplement through the tube. Thirty minutes later, the nurse noticed the patient was cyanotic and having difficulty breathing. The patient's physician was contacted and the patient transferred to the intensive care unit. A chest x-ray revealed that the feeding tube was in the lower lobe of the patient's right lung and not in the correct location in the stomach. The patient developed aspiration pneumonia following this incident and ultimately expired on 6/25. Respecting the patient's "Do Not Resuscitate" request, the caregivers did not attempt cardiopulmonary resuscitation.

Case # 6 On 4/11, a 68-year-old male patient was transferred to your hospital from another facility for a non- invasive outpatient procedure. The patient's diagnoses included congestive heart failure, non-insulin dependent diabetes, edema of the lower extremities with cellulitis, ulcer of his toe, hypertension and bladder outlet obstruction. The patient's medical records from the transferring hospital were sent along with the patient and were available to physicians prior to the procedure. The patient had been receiving oxygen at one liter per minute at the transferring facility and during transport but after admission to your hospital the patient did not receive oxygen because it was not ordered at the time of his admission. The patient underwent the non-invasive vascular study procedure on 4/13. Following the procedure, the patient suffered a seizure and a cardiac arrest. Caregivers started cardiopulmonary resuscitation immediately however continued resuscitation attempts failed. The attending physician documented that the patient's death was due to complications of severe congestive heart failure secondary to cardiovascular disease.

Case # 7 On 6/17 an 84-year-old female in your hospital for pneumonia and chronic obstructive lung disease was found by staff on the floor by her bed. The patient was assessed and found have a laceration on her nose with some bleeding from that area. She also had a bruise on the right shoulder. The patient's physician was notified. Four hours later, a staff nurse noted the patient had a swelling and bruising of the right wrist. The patient's physician was notified again and an x-ray was ordered. The x-ray revealed a questionable non-displaced fracture of the wrist which was treated with an ace-wrap. The nursing staff placed a bed alarm on the patient's bed after this occurrence and no further patient falls occurred. The patient was discharged to home care on 6/25.The home health agency was notified that the patient is at high-risk for future falls and a home safety assessment was recommended

Case # 8 A 36-year-old male patient had elective knee surgery at your hospital on 6/09. The patient had no apparent intraoperative or postoperative complications until he complained of shortness of breath and chest pain at approximately 6:00 PM on 6/11. The orthopedic surgeon assessed the patient, moved him to the intensive care unit and obtained a cardiology consult. The cardiologist assessed the patient and determined that the patient's problems were not cardiac related. A pulmonologist consultation was obtained and a pulmonary scan showed multiple pulmonary emboli. A cardiac surgeon was asked to consult in regards to embolectomy surgery. The surgeon did not choose to operate due to the high risk related to the patient's size (he weighed over 300 pounds). It was decided to treat the emboli conservatively with a heparin drip to dissolve the clots. The drip was started at 8:00 PM on 6/11. The patient had a cardiac arrest at 12:28 PM on 6/12 and all attempts at resuscitation failed. The patient was pronounced at 1:28 PM. The family refused an autopsy and the coroner was not called. Cause of death was noted to be pulmonary embolus.

Case # 9 A 59-year-old male was admitted to your hospital on 4/7 for diagnostic studies related to an occluded internal carotid artery, low grade carotid disease and dilated abdominal aorta. While undergoing a carotid arteriogram, he had a cerebrovascular accident and underwent an emergency carotid endarterectomy. His condition deteriorated while in the recovery room following the endarterectomy and he required two units of packed cells. This caused him to remain in the recovery room for more than four hours. The remainder of the patient's hospitalization was uneventful and he was discharged to home on 4/23

Case # 1 0 A 39-year old male was admitted to your hospital's psychiatric care unit on 4/15 for treatment of depression and suicidal ideation. He was given a physical examination on the day of his admission; however there was a three-day delay in drawing his blood for routine lab work. When these results did return they showed a very high blood glucose level, as did additional tests. By this time the treatment team had determined the patient was ready discharge so the treating psychiatrist, believing the patient needed evaluation of what was likely diabetes, developed a discharge plan that included an immediate outpatient evaluation by the patient's primary care physician. The patient was discharged on 4/27. Twenty-five days later, the patient, who never went to see his primary care physician, was re-admitted to your hospital with severe hyperglycemia. After 48 hours in the hospital, the patient's diabetic condition stabilized. He was started on insulin, received diabetic education and nutritional counseling. The patient was eventually discharged to home on 6/8. His physician ordered a few weeks of home health services to help reinforce what the patient had learned in the hospital.

Case # 11 On 4/23, a 56-year-old female patient in your hospital was getting a pre-surgery antibiotic by intravenous injection when she developed a rash and vomited. The patient's nurse stopped the intravenous antibiotic as soon as the patient experienced difficulties. The patient quickly became unresponsive and hada respiratory arrest. Cardiopulmonary resuscitation was successful. The patient was transferred to the intensive care unit and treated for an anaphylactic reaction. The patient did not have a documented allergy to the antibiotic prior to this hospitalization. The patient's condition stabilized and she was discharged home on 5/1. Her surgery was scheduled for a later date.

Case # 12 On 5/3, a 62-year-old male in your hospital for chemotherapy treatments was found lying at the foot of the stairs in the north wing stairwell (a back exit intended for use by staff only). The patient told the nurse who found him that he had fallen down the stairs. The nurse assessed the patient and found no apparent injury. She helped the patient return to his room. A later examination by his physician revealed minor bruising but no other injuries. Upon investigation, it was found that the alarm on the door to the stairwell had been repaired earlier in the day and the alarm had not been reset. That was why staff was not alerted when the patient opened the door to the stairwell. The patient had no ill effects from the fall and he was discharged home on 5/7

Case # 1 3 On 5/18 a 35-year-old, female patient in your hospital's psychiatric unit failed to return from an authorized six hour off-site pass. The physician and responsible medical staff were notified of the elopement. Attempts made to reach the patient using the telephone number supplied by the patient were unsuccessful. The patient had been assessed and was found not to be a risk to herself or others at the time the pass was issued, however her physician did not yet feel she was ready to be discharged from inpatient care at the time she was given the pass. Discharge procedures were begun on 5/20 when she still had failed to return.

Case # 1 4 On 5/13, a 36-year-old intoxicated male was admitted to your hospital's detoxification unit. Approximately two hours after admission, the patient became violent and as staff intervened, the patient threw a punch at a staff member, striking the staff member in the face. Facility security and the police department were called. The patient was arrested by the police and transported to jail on charges of assault.

Case # 1 5 A 46-year-old female was admitted to your hospital on 4/15 for an abdominal hysterectomy. Three days after her initial operation, the patient complained of abdominal pain. It continued, and on the sixth day her gynecologist did exploratory surgery. At the time of surgery, the doctor discovered that a portion of patient's bowel had slipped through a small hole in the membrane covering her abdomen. This defect, which occurred during the first surgery, was repaired and the patient was transferred to the intensive care unit postoperatively. The next day, the patient had a 103.8 F fever and her urine output sharply declined. A third surgery was performed to remove six feet of necrotic bowel. The patient went downhill rapidly and within 24 hours following the second bowel surgery, she was placed on mechanical ventilation. The patient ultimately developed a septic bacterial infection and kidney failure. Despite aggressive treatment and two more abdominal surgeries, the patient expired on 6/25 secondary to multiple organ failure. The family had requested that the patient not be resuscitated.

Answer 1

Case	Occurence Number(S)
#1	12
#2	02
#3	0
#4	21
#5	04
#6	02
#7	19
#8	02,09
#9	14
#10	05
#11	01,18
#12	0
#13	0
#14	0
#15	21,22,04