For the following questions, consider the following scenario:
A close-up of hands holding a baby’s hand Description automatically generated with low confidence
62 year old female with history of congestive heart failure (CHF) was admitted from the Emergency Department with Left Lower Lobe Pneumonia. She has been living independently at home with no assistance needed with cares. She was complaining of pain with inspiration, vital signs were normal, oxygen saturation was 90% on room air. On hospital day 2, she was found on the floor at 2345 in severe pain. X-rays revealed a hip fracture. The next day she was taken to surgery for repair. During surgery she had an acute myocardial infarction (AMI) and expired while on the table.
Further analysis of the timeline leading up to 2345 discovered that the nurse came on at 2300 that evening and got report which indicated the patient was pleasant and cooperative, asking for help as needed, didnt attempt to get up on her own, used the call light. Looking at the medical record found the patient had been given a sleeping pill and pain medication at 2200, the same as the previous night. The patient doesnt regularly take either a pain or sleeping pill at home.
At 2330, the nurse checked the patient to do vital signs, found her dozing but easily arousable although a little confused when first awakened. The unit became busy as they just received a fresh surgical patient post operatively.
At 2345, a nurse walking by the room heard a noise and went to investigate. She found the patient on the floor and called for help. The patient had been incontinent of bed and gown, the floor was dry. They had to move furniture in the room to get at patient as there were extra chairs in the room after her family visited that evening. Her oxygen tubing was wrapped around her IV pump. The physician came immediately and assessed the patient. X-rays were ordered and the patient was taken to x-ray. The x-rays revealed a hip fracture. Orthopedics saw the patient and scheduled her for surgery the next day. She was prepared for surgery and sent the next day.
QUESTION 1 of 4
What are some questions that the team investigating this adverse might want to ask as they investigate?
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QUESTION 2 of 4
What were the biggest patient safety risks based on the information available?
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QUESTION 3 of 4
Choose one of the patient safety risks you identified in the previous question. How did that risk factor contribute to the adverse events in the scenario?
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QUESTION 4 of 4
What is one evidence-based solution or strategy that could help mitigate the risk factor(s) you have identified?
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