Download Case Study Assignment

CLARION INTERPROFESSIONAL CASE COMPETITION
CLARION
An Interprofessional Student Committee of the
Centre for Health Interprofessional Programs (CHIP)
UNIVERSITY OF MINNESOTA
A preventable patient death at Royal Academy Hospital?
Written by
Karyn Baum, M.D.
Assistant Professor
Department of Medicine
General Internal Medicine
University of Minnesota
Sandra Potthoff, Ph.D.
Associate Professor and
MHA Program Director
Carlson School of Management
University of Minnesota
Don Uden, Pharm.D.
Professor
Pharmaceutical Care and Health Systems
Associate Dean for Student Services
University of Minnesota
William Riley, Ph.D.
Associate Professor and Associate Director
Division of Health Services Research and
Policy
School of Public Health
University of Minnesota
Karin Alaniz, RN, Ph.D.
Senior Teaching Specialist
School of Nursing
University of Minnesota
Jake Rosenberg
MHA Candidate, Class of 2005
Carlson School of Management
University of Minnesota
Case modified by Greg Ogrinc, Andy Carson-Stevens and Sharon Mayor
for
Quality Improvement Academy for health, social care and public health in Wales
June 25-27 2009
Royal Academy Hospital
Page 1 of 10
This case study was prepared for the CLARION Interprofessional Case Competition. It was developed as the basis for discussion in
the Case Competition. Information in this case is fabricated/fictitious. Any resemblance to any healthcare provider is purely
coincidental. No part of this publication may be reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in
any form or by any means-electronic, mechanical, photocopying, recording, or otherwise without the permission of the University of
Minnesota. © University of Minnesota Board of Regents, 2005.
Case Study Assignment
The Chief Executive of the Royal Academy Hospital has asked your interprofessional team to
study this event. Please use root cause analysis (RCA) techniques to accomplish your task. You
will be presenting your findings, conclusions, and recommendations to the Patient Safety
Committee of Royal Academy Hospital on 27 June, 2009. Your team will have 5 minutes to
present an overview of how and why these events occurred and to outline a plan of action to
prevent them from occurring in the future. The case is rather detailed and you may identify
several root causes. Because this is a focused presentation (~5 PowerPoint slides using the
template), please centre your presentation on the most important cause of this event. A 3 minute
question period will follow your presentation. In studying the event, your team should make
sure that your analysis, findings, and recommendations focus on systems and processes that need
to be improved, changed, eliminated, or implemented.
Background
Royal Academy Hospital
Royal Academy Hospital is a tertiary care centre in an urban setting in Wales. Originally
founded in 1900 as a 100 bed acute care facility, the hospital now has 1000 inpatient beds.
Special wards in the hospital include a medical/surgical Intensive Care Unit (ICU) with 20 beds,
a cardiac ICU with 25 beds, a maternity unit with 40 beds, a rehabilitation ward with 37 beds,
and a psychiatric ward with 15 beds.
The hospital offers a full range of tertiary care inpatient and outpatient services including:

Complete medical, surgical and critical care;

Trauma services;

Multi-specialty care and clinical expertise centres of excellence in behavioural health,
cardiovascular services, medical/surgical services, neuroscience, oncology, orthopaedics,
rehabilitation, spinal injury care and women's health;

Outpatient care is provided in more than 50 different specialty areas;

Education programs, support services and public health screening.
Royal Academy Hospital
Page 2 of 10
This case study was prepared for the CLARION Interprofessional Case Competition. It was developed as the basis for discussion in
the Case Competition. Information in this case is fabricated/fictitious. Any resemblance to any healthcare provider is purely
coincidental. No part of this publication may be reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in
any form or by any means-electronic, mechanical, photocopying, recording, or otherwise without the permission of the University of
Minnesota. © University of Minnesota Board of Regents, 2005.
Royal Academy Hospital is part of the John Toshack University Trust (JTUT). In addition to
Royal Academy Hospital, JTUT receives referrals from 28 general practitioner practices
throughout the region.
Royal Academy Hospital has Consultant-led teams delivering care to medical and surgical
patients in the hospital. Each consultant-led team is on a rota to provide round-the-clock
coverage throughout the hospital. Its intensive care ward is staffed with doctors and nurses
around the clock.
Nurse staffing on the general medical/surgical wards is about 4:1 (4 patients per nurse). During
day and evening shifts, for a ward with 28 patients, there will generally be 8 nurses working, one
of whom is the ward Sister and is not assigned to any patients. There are also two certified
nursing assistants and a ward coordinator during these shifts. The two nursing assistants on each
shift are evenly split between the nurses, and each reports to the nurses to whom he or she is
assigned. On the night shift, there will typically be seven nurses for a patient census of 28, one
of whom is the Sister and not assigned to individual patients. In addition, on the night shift there
is one paraprofessional who works at the desk and as a nursing assistant combined.
Royal Academy Hospital is staffed with 35 full-time pharmacists and 40 full-time pharmacy
technicians. The floors have decentralized pharmacists. Each medical ward has Pyxis
Medstation automated medication management systems (see Appendix 1).
Each ward has a social worker and a care coordinator to aid in discharge planning for patients.
The social worker and care coordinator review the new admissions each morning and divide
them up accordingly. Patients that are likely to need transitional care placement are followed by
the social worker. Other patients are generally followed by the care coordinator, although
decisions are made on a patient-by-patient basis. The social worker or care coordinator meets
with the patient and/or their family within 24-36 hours of admission to begin assessing
anticipated discharge needs, and often writes a note in the patient’s notes. The social worker and
Royal Academy Hospital
Page 3 of 10
This case study was prepared for the CLARION Interprofessional Case Competition. It was developed as the basis for discussion in
the Case Competition. Information in this case is fabricated/fictitious. Any resemblance to any healthcare provider is purely
coincidental. No part of this publication may be reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in
any form or by any means-electronic, mechanical, photocopying, recording, or otherwise without the permission of the University of
Minnesota. © University of Minnesota Board of Regents, 2005.
care coordinator also try to meet with the Consultant-led teams to discuss each patient, but often
communication takes place only through the patient’s notes.
Implementation of an Electronic Medical Record (EMR) at Royal Academy Hospital is just
beginning. Full scale implementation is currently in its second week, after an initial pilot
implementation on one of the wards. All clinicians are using the system – nurses, doctors,
pharmacists, social workers, care coordinators, etc. Unfortunately, the learning curve has been
steep. Because of unfamiliarity with the EMR, it has taken nurses longer to complete their
documentation, and the nurses are complaining that they have less time to spend with patients
and interact with the physicians. Physicians and other clinicians have also reported that
documentation and decision making are taking more time than with the previous paper based
system.
A preventable death?
Thursday, 9 am
A bus driver in the city centre was being yelled at by one of his passengers. He had picked up
the woman a few stops previously, and had immediately thought that she “might be trouble.”
The woman had stumbled onto the bus, and sat muttering incoherently; the other passengers
moved as far away as possible.
Fifteen minutes later, the woman demanded that he stop the bus at a Bargain Booze corner shop.
As it was not a registered stop, he politely told her that she could get off at the next bus stop. The
woman then began yelling at him, used profanity, and accused the driver of talking about her to
the other passengers behind her back. He had had enough. He threw the woman off the bus at
the next stop and radioed to his supervisors, asking them to call the police.
When the police arrived a few minutes later, they found the passenger lying face down in gravel.
She has fallen on to an old iron peg lodged in the ground. Observers described her fall as a
‘sickening thud’. She had a deep cut extending from the top of her thigh around to the crest of
her hip around 12cm in length. When they attempted to ask her about her side of the story, they
Royal Academy Hospital
Page 4 of 10
This case study was prepared for the CLARION Interprofessional Case Competition. It was developed as the basis for discussion in
the Case Competition. Information in this case is fabricated/fictitious. Any resemblance to any healthcare provider is purely
coincidental. No part of this publication may be reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in
any form or by any means-electronic, mechanical, photocopying, recording, or otherwise without the permission of the University of
Minnesota. © University of Minnesota Board of Regents, 2005.
were unable to wake her up. She was breathing and had a good pulse. They called the
paramedics.
When the paramedics arrived, they noted that the patient was confused and drowsy. Her vital
signs revealed a pulse of 88 beats per minute, respiratory rate of 14 per minute, a blood pressure
of 140/88, and a temperature of 37C. She was taken to the Accident and Emergency Department
(AED) at Royal Academy Hospital for further care. She did not have any identification on her.
Thursday, 10 am
Upon arrival at the AED, the patient was lethargic and unable to give a history. Two A&E
doctors quickly evaluated her. She had pin-point pupils and a dysconjugate gaze (both eyes
moving in opposite directions). She was given naloxone (a drug to reverse the effects of opioids
e.g. morphine or heroin), glucose IV (in case the patient was hypoglycaemic and/or diabetic),
and oxygen, none of which had any effect upon her mental status. Her lung and heart sounds
were normal. Her abdominal exam was normal as well. The doctors could not perform a full
neurological examination due to the patient’s mental status, but she did have normal reflexes and
withdrew from pain. She was intubated as she was not able to protect her airway from her own
salivary secretions.
Ruth Burns, the staff nurse assigned to care for her in A&E, found a bottle of pills in the
patient’s trousers, with the name Tina Norman on them. The pill bottle was from a local
pharmacy, and it was evident from the dated label on the bottle that it had been filled that day. It
was noted to be clozapine (Clozaril), 100mg tablets (an antipsychotic sedative drug and
sometimes used for treatment of treatment-resistant schizophrenia). The directions were to take
one tablet per day, and the label noted 12 had been dispensed. There were only seven pills left in
the bottle. The nurse let one of the A&E doctors know this information immediately.
A CT head scan was done and was reported by the trainee radiologist as being negative for any
acute stroke or bleeding. A X-Ray of the hip was done and was also reported with no significant
findings. Bloods were sent for a complete blood count and electrolytes were normal. A urine
Royal Academy Hospital
Page 5 of 10
This case study was prepared for the CLARION Interprofessional Case Competition. It was developed as the basis for discussion in
the Case Competition. Information in this case is fabricated/fictitious. Any resemblance to any healthcare provider is purely
coincidental. No part of this publication may be reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in
any form or by any means-electronic, mechanical, photocopying, recording, or otherwise without the permission of the University of
Minnesota. © University of Minnesota Board of Regents, 2005.
toxicology screen and a urine pregnancy test were performed and both were negative. Her ECG
was normal. Her cut was cleaned, sutured and dressed. The presumptive diagnosis was a
Clozaril overdose, and the patient was admitted to the ICU for further care. All of her
belongings were placed in a bag and sent with her to the ICU.
Thursday, 2 pm
The intensive care doctor in the ICU, Dr Katie Simmons, called the ICU pharmacist, who was
sceptical about Clozaril alone causing the patient’s condition. The therapeutic dose of Clozaril
was usually 25 to 900 mg per day. A serum toxicology was sent to the lab, and a lumbar
puncture for cerebrospinal fluid analysis was normal. At this point, Dr. Simmons assumed that
Ms. Norman had overdosed on her Clozaril, but still suspected that she had taken another
medication or an illicit drug.
She was sedated throughout the night.
Friday, 7 am
Dr. Simmons received a brief handover from a colleague who discussed an uneventful night for
the patient. The nurses were currently doing their handover and Dr Simmons proceeded to do a
ward round. She saw that the patient seemed less agitated now, and her sedation was wearing off.
She could respond to yes and no questions. Her vital signs and morning blood results were all
within the normal range, so it was decided to extubate the patient.
Following extubation, the patient was able to give a little more of her history. She said that she
thought that she was supposed to be on 500mg of Clozaril, and that she was only following what
she thought were her doctor’s orders when she took that amount. She adamantly denied taking
any other medications or illicit substances. She seemed rational and was very cooperative.
The psychiatry team came to see Ms. Norman at 10 am. She stated that she was first diagnosed
with schizophrenia 20 years ago, at the age of 16. She said that she had been on several
medications, but none had worked terribly well or for terribly long. She quit school at 17, and
Royal Academy Hospital
Page 6 of 10
This case study was prepared for the CLARION Interprofessional Case Competition. It was developed as the basis for discussion in
the Case Competition. Information in this case is fabricated/fictitious. Any resemblance to any healthcare provider is purely
coincidental. No part of this publication may be reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in
any form or by any means-electronic, mechanical, photocopying, recording, or otherwise without the permission of the University of
Minnesota. © University of Minnesota Board of Regents, 2005.
was currently working as a cleaner at a local shopping centre. She stated she only drinks when
her psychiatric illness is out of control. For the past week she had been drinking about one fifth
of a large bottle of vodka per day. She has no family or close friends.
Friday, 11 am
Dr. Simmons checked in on Ms. Norman again. She seemed to be doing fine. Dr. Simmons
spoke with Gary Perkins, the staff nurse taking care of Ms. Norman for the day shift. They both
felt that she was stable, and could be transferred out of the ICU to free up the bed. She was to be
transferred to ward 10, an unmonitored medical ward.
The on-call Consultant for the ward to which Ms. Norman was being transferred called Dr.
Simmons about the admission, and Ms. Norman was discussed with him. He then called the
senior house officer on his team to notify him of the admission. The senior house officer, Dr
James Martin, went to the ICU to meet the patient. Dr. Martin talked with Ms. Norman in the
ICU, who by this time was alert and sitting up in bed, eating lunch. Dr. Martin typed the transfer
orders into the EMR and then went back to caring for his other patients and new admissions.
There was still no bed for Ms. Norman, so she remained in the ICU until a bed was available.
Friday, 1pm
On moving around in her bed, Ms. Norman became increasingly aware of a pain in her side. She
disclosed this to the auxiliary nurse, Tina Evans. Ms. Evans told the patient she had had ‘quite a
fall’ and the pain is probably from the deep cut she sustained on falling to the ground and she
would mention it to Nurse Gary Perkins when he got back from his break.
Friday, 1:10pm
At 1:10 pm Anne Brown, the Sister on ward 10, a medical ward, called the ICU to let them know
that a bed was finally available for Ms. Norman. It was a bed near the nursing station. Whilst
Ms. Norman’s assigned nurse was on his break, the ICU sister handed over the patient to Nurse
Susan Hunt on Ward 10. The ICU Sister indicated that there was no concern that Ms. Norman
may try to intentionally hurt herself.
Royal Academy Hospital
Page 7 of 10
This case study was prepared for the CLARION Interprofessional Case Competition. It was developed as the basis for discussion in
the Case Competition. Information in this case is fabricated/fictitious. Any resemblance to any healthcare provider is purely
coincidental. No part of this publication may be reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in
any form or by any means-electronic, mechanical, photocopying, recording, or otherwise without the permission of the University of
Minnesota. © University of Minnesota Board of Regents, 2005.
Ms. Norman was then transferred upstairs to a 4-beded ward. Her belongings were transferred
with her, which were still in the bag with her name on it from ICU. The bag was placed in the
cupboard next to her bed. She settled in, had an early supper, and again briefly talked to Dr.
Martin.
At this point, Dr. Martin ordered a normal diet, and activity as tolerated. After consulting with
his Consultant, he decided to continue to withhold the Clozaril. The psychiatry team stopped by
briefly, and agreed with Dr. Martin. The psychiatry team was still not clear that Clozaril was the
only drug taken that could have caused Ms. Norman’s condition, as the dose was not that large.
They planned to come back in the morning to see how Ms. Norman’s condition progressed
overnight.
Friday, 6:30 pm
At 6:30 pm Michelle Robbins, a patient in the next bed to Ms. Norman, rang for the nurse.
Michelle said that she saw her take some medication from her cupboard. Susan Hunt, a staff
nurse, went to the room once she had completed doing a complicated dressing change on one of
her other patients, which was about 7 pm. There was indeed an empty bottle of Clozaril on Ms.
Norman’s bed, the same bottle that she had with her when she arrived. Ms. Norman nodded
affirmatively when she was asked if she had taken the medicine. The nurse paged the on-call
junior doctor, Dr Norma Grant, to describe to her what had happened. Susan requested that she
come to assess Ms. Norman. Dr. Grant told her that she was admitting a critical patient and
would be there as soon as she could. By the time Dr. Grant arrived, about 7:30 pm, Ms. Norman
was very lethargic and unable to answer questions. She was drooling a bit and coughing lightly.
She had a gag reflex, and her pupils were equal sized and responsive to light. Dr. Grant quickly
called her senior house officer, Dr Abel Payne, for help.
Dr. Payne arrived about 5 minutes later. Ms. Norman seemed to be choking a bit on her
secretions, so an anaesthetist was called immediately. They reintubated Ms. Norman and
transferred her back into the ICU.
Royal Academy Hospital
Page 8 of 10
This case study was prepared for the CLARION Interprofessional Case Competition. It was developed as the basis for discussion in
the Case Competition. Information in this case is fabricated/fictitious. Any resemblance to any healthcare provider is purely
coincidental. No part of this publication may be reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in
any form or by any means-electronic, mechanical, photocopying, recording, or otherwise without the permission of the University of
Minnesota. © University of Minnesota Board of Regents, 2005.
Next week
In the ICU, Ms. Norman had another uneventful stay. She was extubated about 24 hours later,
after regaining consciousness. The psychiatry services saw her again, and on Monday she was
transferred to an inpatient psychiatry team for further care. The psychiatry inpatient team hold
ward rounds on Monday and Friday each week. 1It was agreed she would remain on a medical
ward for nursing care whilst she struggled to move around as a result of the pain in her hip and
this would be reviewed on Friday. She remained bed bound whilst the ‘wound was healing’
making occasional but painful visits to the toilet. During her time on the ward, Ms Norman
thought she might be allergic to something in the ward since she was experiencing symptoms
similar to asthma that she recalled from her teenage years. The team prescribed some antihistamines daily and Salbutamol if required.
At 2am on Tuesday morning, Ms. Norman buzzed for the nurse to complain about the pain in her
side since it was preventing her from sleeping. The on-duty Ward Sister, Susan Green, took a
look at the wound and it did not appear to be infected. The on-call psychiatry house officer
received a call from Ward Sister at 2:45am and was instructed to prescribe Paracetemol and
Ibuprofen as required. She told the doctor: he could examine the patient’s hip in the morning if
he wished; she will give Ms. Norman two Paracetemol and Ibuprofen 400mg immediately; and
he can authorize the drugs on the system in the morning and he should go back to sleep.
Thursday, 3:20 am
The patient next to Ms. Norman buzzed for the nurses since she was awoken by Ms. Norman’s
apparent struggle to breathe. The patient was becoming increasingly short of breath and
eventually lost consciousness. The on-call medical team was bleeped but they were already
attending to a cardiac arrest. The nurses gave Ms Norman oxygen and bleeped the on-call
intensive care doctor. They queried the possibility of a further overdose but deemed this unlikely
since she no longer kept a medication supply. By the time the intensive care doctor and the
11
Royal Academy Hospital
Page 9 of 10
This case study was prepared for the CLARION Interprofessional Case Competition. It was developed as the basis for discussion in
the Case Competition. Information in this case is fabricated/fictitious. Any resemblance to any healthcare provider is purely
coincidental. No part of this publication may be reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in
any form or by any means-electronic, mechanical, photocopying, recording, or otherwise without the permission of the University of
Minnesota. © University of Minnesota Board of Regents, 2005.
medical team had arrived, Ms. Norman was receiving Cardiopulmonary Resuscitation from the
nursing team. Time of death declared at 4:10am.
Coroner’s investigation
Re-examination of the plain film X-Rays taken on admission to A&E revealed a subtle nondisplaced fracture of the hip. This was not spotted by the trainee Radiology doctor. On coroner’s
inquest, the cause of death was reported as a pulmonary embolism secondary to hip fracture.
Appendix 1
The Pyxis MedStation system is the leading automated dispensing system supporting
decentralized medication management. Barcode scanning to help ensure accurate medication
dispensing, features to prevent loading of the wrong medication and active alerts to provide an
added safety precaution for high risk medications are just a few of the ways the Pyxis
MedStation system can help your facility support safe and efficient medication management.
Royal Academy Hospital
Page 10 of 10
This case study was prepared for the CLARION Interprofessional Case Competition. It was developed as the basis for discussion in
the Case Competition. Information in this case is fabricated/fictitious. Any resemblance to any healthcare provider is purely
coincidental. No part of this publication may be reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in
any form or by any means-electronic, mechanical, photocopying, recording, or otherwise without the permission of the University of
Minnesota. © University of Minnesota Board of Regents, 2005.