Chester Hill Regional Hospital is a large urban hospital located in central Arkansas, dedicated to improving the health of its local community. Due to the recent shut down of another local facility, Chester Hill has seen a dramatic increase in their inflow of patients, specifically within the emergency department. The hospital is currently short-staffed, and many employees feel overworked and burnt out. The Friday and Saturday shifts are predominantly bad, and almost all nurses and physicians dread coming to work.
During a very busy Friday evening, a 47-year-old female patient, Mary, came into the emergency department complaining of serious abdominal pain. The patient had been drinking throughout the day due to a family event, and upon entry her blood alcohol level was .301, which left her severely impaired. When evaluated by the admitting nurse, Mary noted her pain as an 8 out of 10. Dr. Edward Dennis, one of the emergency department physicians, briefly reviewed the chart and immediately ordered fluids and pain medication. Dr. Dennis ordered that the patient be monitored every 20 minutes and noted for nurses to keep an eye on the patient’s blood pressure for any dramatic jumps.
As the emergency department continued to fill with other patients, Mary was moved into an overflow room. Nurses were extremely busy with other recently admitted patients; therefore, no one was able to closely monitor Mary’s blood pressure. As Dr. Dennis returned to check back on Mary several hours later, he found her in cardiac arrest. Despite the efforts of Dr. Dennis and the rest of the emergency staff, they could not resuscitate Mary. An autopsy revealed the cause of Mary’s death was her blood alcohol content, mixed with hydromorphone.
As Dr. Dennis and the ED nurses reviewed the autopsy results and reflected on Mary’s case with the hospital’s CMO, Dr. Dennis instantly became defensive. He quickly explained that he was unaware of the patient’s blood alcohol content, and if he had known, his course of treatment would have differed. In addition, Dr. Dennis expressed that he assumed the nurses would have monitored the patient closely and administered the appropriate amount of pain medication, based on Mary’s response. On the opposite end of the spectrum, the nurses attested that Dr. Dennis never ordered the patient to be closely monitored.
Discussion Questions:
- What are the primary issues and concerns in this case? What are the organization’s strengths and weaknesses?
- Is there a correlation between teamwork and communication and medical errors? How can Dr. Dennis and the rest of the ED staff ensure they communicate effectively during busy shifts? You are the Chief Medical Officer assigned to investigate Mary’s case. How do you effectively address Dr. Dennis?
- What liability does Chester Hill Regional Hospital have in this case?
- In order to prevent this type of incident from occurring again, how must Chester Hill address the staffing of its emergency department?
- Discuss what quality improvement tool (i.e. flowchart, Fishbone diagram) might be used to assess what went wrong and determine how to prevent future occurrences
Sample Solution
