CASE # 1: Communication of Patient Information During Transitions in Care Margar

Question

CASE # 1: Communication of Patient Information During Transitions in Care

Margaret Burns is a 63-year-old woman who has suffered a left occipital hemorrhagic infarct, a cerebrovascular event. In addition to this recent stroke, Margaret has a history of rheumatoid arthritis, which limits her mobility; hypertension, which has been controlled with diet and medication; osteoporosis; gastroesophageal reflux; and depression. She is alert and oriented, and has been identified at risk for falls. She requires moderate assistance with transfers and minimal assistance with ambulation using a rolling walker. Her scheduled medications include: pantoprazole for gastroesophageal reflux disorder (GERD); alendronic acid for osteoporosis; prednisone, a steroid; metoprolol for hypertension and heart disease; and calcium with vitamin D.

Following her acute care hospitalization, she is transferred to a skilled nursing and rehabilitation facility to continue her recovery. Margaret lives alone and must be independent to return home. One week after her admission to the skilled nursing facility, Margaret develops pain and swelling in her right leg and a low grade temperature. Her blood work indicates an elevated white blood cell count. The attending physician orders a venous Doppler ultrasound of the right leg and the results are positive for an acute deep vein thrombosis (DVT). Plans are made to transfer Margaret back to the acute care hospital for possible placement of a filter as she is not a candidate for anticoagulation due to her hemorrhagic stroke.

Carol Stevens, the secretary on Margaret’s unit at the skilled nursing facility, had a flat tire on the way to work. After calling the auto club and waiting for them to come and change the tire, she arrives late, already behind before her day has even started. After she punches in and hurries to the unit, she learns two patients are being discharged, two other patients are scheduled to arrive for admission, and Mrs. Margaret Burns is scheduled to be transferred to the acute care hospital. She immediately sets to work faxing the histories, current lab results, consults, diagnostics, physician progress notes, nurses’ notes, and medication administration records to the physicians of the patients to be discharged and making copies of those items to send to the hospital with Mrs. Burns per protocol for continuity of care, keeping each set of patient records in a separate pile.

Carol’s son then calls to say that he missed the school bus. Carol sets the papers aside while she calls a neighbor to arrange transportation for her son. As she hangs up the phone, the ambulance arrives to transport Margaret to the hospital. Carol gathers the copies of Margaret’s records together and places them in an envelope. The hospital process is for a nurse to double check the records to ensure they are correct prior to the patient leaving the building, but another ambulance crew arrives simultaneously with a patient for admission, handing that patient’s paperwork to Carol. Carol hands the envelope with Margaret’s records to the first crew without double checking the papers and Margaret is transported to the acute care hospital. The receiving unit at the acute care hospital doesn’t notice that the patient and chart do not match.

A week later, the patient care coordinator at the skilled nursing and rehabilitation facility receives a call from the acute care hospital and is informed the medication administration record sent with Margaret Burns was that of another patient. The acute care hospital failed to notice this discrepancy on admission, and the wrong medications were ordered and administered to Margaret for three days. Margaret suffered an extension of her hemorrhagic stroke and was transferred to the ICU.

Answer the following questions in paragraph form:

1.     As the director of quality improvement at the skilled nursing facility, what are the quality control problems in this case? Identify and explain the major issues in this case.

2.     Which health care facility is responsible for the medication errors? What are the legal and ethical obligations a health care organization has to its patients and families, and how do they apply to this case?

Explanation / Answer

Answer 1.

The main quality control problems in this case are:

Answer 2.

Medication errors are the most common types of errors occurring in the hospital facility. This is a severe case of negligence. None of the agencies thought of cross-checking the reports, medicines and the patients’ name. The main facilities responsible in this case are the nurses who are administering the medicines. Apart from these, the hospital staff bringing the patient to the hospital is also responsible.

All health care organizations are bound to comply with the legal obligations related to care of patients. All hospital staff (clinicians as well as workers) should be aware of the NSW health policy and the relevant legislation. For public health organisations, “Health Services Act, 1997” applies to this case. Apart from this, the hospital can be punished on grounds of “Health Administration Act, 1982” as well.

This hospital has failed to comply with the legal obligations; inadequacy and negligence in patient care has been observed.

Note that the various legal obligations can be studied in detail from the ‘nsw’ website.

The ethical obligations are:

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