In the book Patient Safety for healthcare professionals it states, “Rosie is a 7

Question

   In the book Patient Safety for healthcare professionals it states, “Rosie is a 79-year-old woman with hypertension, arthritis, diabetes, and chronic periodontal dental problems. She lives alone in a trailer in a rural county 40 miles away from a major city. She has no family and does not drive. Her 70-year-old neighbor, Fred, lives about 10 miles down the road and checks on Rose weekly. He takes Rose to doctor appointments and helps with weekly errands. Rose cooks, pays bills, and does light housekeeping. She especially enjoys the company of her television. She has difficulty hearing the telephone. She sits in a recliner 4 to 5 hours per day with the heels of her feet against the calf support of the recliner.
   She received a check up from her physician a year ago. Rose scored 28/30 (minimal impairment) not the Mini-Mental State Examination. At that time, she was diagnosed as having stage II pressure sore on the dorsum of the right heel. The doctor reminded Rose to change positions often and to keep pressure off the heel. Rose did not keep her scheduled follow-up appointment with the doctor a month later.
   Rose decided to apply elastic stockings (T.E.D. hose) last week (T.E.D. is a licensed trademark of TYCO International [U.S.]). The stockings were previously issued a year ago for management of lower-extremity edema. Because of joint pain in her hands and fingers associated with arthritis and difficulty applying the hose, she decided to leave the shoe on. She slept in the hose for 7 days. This week Rose began to experience some discomfort in her foot with weight bearing. Fred stopped by to drop off the groceries and noticed some bleeding around the heel. Rose told Fred that she has even taking some Darvocet that she had left over from a dental terday. Fred decided that her problems were serve enough to take her to the emergency department at the local hospital. The T.E.D. hose were removed, and the wound was cultured. The culture revealed methicillin-resistant Staphylococcus aureus colonization. She was admitted to the hospital for 3-day stay. A team conference (including Rose, Fred, Rose’s physical therapist, her occupational therapist, her social worker, and her pharmacist) was called to develop her discharge care plan. The team’s recommendations were forwarded to Rose’s physician.”

1. What do you think about the quality of Rose’s health care?
2. What error were made in this case? Can you differentiate between latent and active errors?
3. Was harmed incurred? Was it likely preventable? How?
4. Identify two system failures in this case.
5. What are the responsibilities of the healthcare professionals in this case?
6. What are the responsibilities of the patient in this case? Of Rose’s “caregiver”?

Explanation / Answer

1. The quality of Rose's health care is appropriate as they have provided her instruction but since Rose is continously not showing up in her follow up check up's,health care person should have notified her about the schedule of the check up.

2. Errors made from Rose side : not attending follow up check up which she should have done , should not have sat on recliner for 4 to 5 hours daily, she should not have slept in hose for 7 days continously, flowing of blood was not proper due to her carelessness.

Error from health care side: not providing a helper or nurse who could have taken daily basis care for the patient as she was alone and far away from the hospital premises area.

the health care should have not planned so early release or discharge of the patient since she was identified with methicillin-resistant staphylococcus aureus colonization infection. She should be treated well so spreading of infection should have prohibited.

3.yes the harm was still not cured as she was only kept for three days observation. proper treatment and medication should have been provided for the patient. Yes the scenario could have been prevented if some health care person was appointed on a daily basis to do a health check for her. the diagnosis could have been done earlier.

4. Two system failures:

1. early release of patient discharge care plan was proposed without consulting physician.

2. Most of the decision of taking medicine, hose etc. were taken by patient alone.

5. They should have taken the case seriously as a health care person they might have provided insurance facilities as well as done her treatment under free cost plan.

6. She should have taken the follow up check up seriously as she ignored and as a result her condition became more worse. Neighbour should have attended her twice or thrice a week.

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