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Institute for Healthcare Improvement: An Extended Stay 11/2/15, 5:51 PM

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Case Study

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An Extended Stay
Instructions to facilitate this activity
Ross Hilliard, MD, IHI Open School Northeast Regional Chapter Leader in a group setting:
Case Studies
Learning Objectives: At the end of this activity, you will be able to: Facilitator Version
Games and
Exercises Explain how system failures can lead to patient harm. Participant Version

Patient Stories Describe how lack of communication between providers and hospital departments
can lead to patient harm
Publishing Your
Work Discuss how to debrief with colleagues after an adverse event. Related IHI Open School online
Other Resources Description: A 64-year-old man with a number of health issues comes to the hospital
because he is having trouble breathing. The care team helps resolve the issue, but PS 101: Fundamentals of Patient
forgets a standard treatment that causes unnecessary harm to the patient. A Safety
subsequent medication error makes the situation worse, leading to a stay that is much
PS 102: Human Factors and Safety
longer than anticipated.
PS 105: Communicating with Patients
Mr. Stanley Londborg is a 64-year-old man with a long-standing history of a seizure after Adverse Events
disorder. He also has hypertension (high blood pressure) and chronic obstructive
pulmonary disease (COPD). He is no stranger to the hospital because of his health
issues. At home, he takes a number of medications, including three for his COPD and
three levetiracetam, lamotrigine, and valproate sodium to help control his
seizures. Key Topics:

Care coordination and transitions, engage

Mr. Londborg came to the emergency
patients and families in care, handoffs,
department (ED) last week because he
leadership, reliable processes,
was wheezing and having trouble communication, teamwork, adverse event,
breathing. The physician in the ED medication safety.
conducted a physical examination that
yielded signs of an acute worsening of his
COPD, which is known as COPD
exacerbation. (In many cases, COPD
exacerbation is the result of a relatively
mild respiratory tract infection, but could
be due to something more serious, such as pneumonia.)

The physician in the ED ordered a chest x-ray, which did not show any signs of
pneumonia. He admitted Mr. Londborg to the hospital for treatment of acute COPD
exacerbation, resulting from a relatively mild respiratory tract infection. Before leaving
the ED, Mr. Londborg also underwent routine blood work, which showed an elevation in
his creatinine, a sign that his kidneys were being forced to work harder due to his

On the medical floor, the care team treated Mr. Londborg with oral steroids and inhaled
bronchodilators (standard medical therapy for his condition), which resulted in a gradual
improvement in his respiratory symptoms. Nurses also gave him IV fluids for the issue
with his kidneys, which slowly resolved.

Mr. Londborg was steadily improving, so it seemed this visit to the hospital would be
one of his shorter ones. Page 1 of 4
Institute for Healthcare Improvement: An Extended Stay 11/2/15, 5:51 PM

But on his third morning in the hospital, Mr. Londborg complained to the intern (a first-
year resident) on the care team about acute pain in his left leg. This symptom,
potentially indicating deep venous thrombosis (a blood clot in his leg commonly known
as DVT), prompted the team to order an ultrasound of Mr. Londborgs lower extremities.
(A primary concern with DVT is that blood clots in the legs may dislodge and travel to
the lungs, causing a pulmonary embolism, which could be deadly.)

The resident on the care team (who oversees the intern) then checked Mr. Londborgs
medication orders and was surprised to see that the admitting doctor had not ordered
prophylaxis for DVT (i.e., blood thinners, such as heparin or enoxaparin). The resident
was surprised because patients admitted to the hospital typically receive this treatment
to prevent blood clots from forming while they lie in their hospital beds. Further, nothing
about Mr. Londborgs medical record suggested he shouldnt have received this
treatment as an important precautionary measure.

Lets pause to consider and discuss a couple questions about the case before we

Discussion Questions:

1) The patient did not receive standard treatment to prevent the formation of a DVT.
What are some possible reasons why this error occurred?

2) Can you suggest system process improvements that might reduce the likelihood of
similar errors in the future?

Click here to read faculty responses

Now lets continue with the story

The ultrasound, unfortunately, confirmed the presence of a blood clot in Mr. Londborgs
left calf. Due to his impaired kidney function, treatment for the blood clot required him to
remain in the hospital on IV medication.

Mr. Londborgs stay was going to be longer than expected.

At 10 PM on his eighth day in the hospital, a member of

the environmental services (also known as
housekeeping) staff found Mr. Londborg on the floor of
his room. She immediately alerted the nurses on the
ward. The nurses noted seizure activity and called the
overnight medical team to Mr. Londborgs bedside. The
team responded quickly and gave him intravenous
medication that stopped his seizure.

Because no one witnessed his fall and seizure, Mr.

Londborg underwent an emergent CT scan of his head to check for any sign of
bleeding. After his mental status improved (it is common for patients to be confused for
a time after a seizure), he complained of pain in his left shoulder and elbow, but x-rays
of these joints showed no evidence of a traumatic fracture from his fall.

After ensuring that Mr. Londborg was stable, the overnight care team reviewed the chart
and the medication history to try to determine the cause of Mr. Londborgs sudden
seizure. They found that one of his seizure medications, levetiracetam, had not been
given earlier in the day when it should have been. There was a notation in the
medication administration record from the daytime nurse indicating that the ordered
dose was not available in the automatic medication dispensing system on the floor
earlier in the day.

Further discussions the following day with the daily care team of doctors and nurses
revealed that the nurses didnt notify the physicians or the pharmacy that the essential
medication was not administered. The medication system didnt include an automatic
alert, either. Page 2 of 4
Institute for Healthcare Improvement: An Extended Stay 11/2/15, 5:51 PM

Fortunately, the overnight physicians restarted Mr. Londborg on his medication, and he
suffered no apparent permanent harm. Mr. Londborg was discharged after 10 days in
the hospital. Most hospitalizations for COPD are far shorter. In fact, many last only a
couple days.

Discussion Questions:

1) Unfortunately, Mr. Londborg suffered a seizure, a complication that could likely have
been avoided if he had received all of the ordered anti-seizure medications. Identify at
least two specific errors that contributed to this mistake.

2) Based on the types of errors you just identified, can you identify systems
issues/failures that affected Mr. Londborgs hospitalization?

3) Identify at least one thing that went well during Mr. Londborgs visit to the hospital.

4) Pretend you are the nurse manager on the ward where this adverse event occurred.
(In most hospitals, the nurse manager is responsible for daily operations on a given
floor or unit, including the nurses and others who work there.) How would you run a
meeting to debrief team members in the days after Mr. Londborgs seizure?

Click here to read faculty responses



Remaining characters (max: 1000): 1000

by Mario Madureira 2/1/2015 8:23:40 AM
A power full exemple to use at class room

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by Margaret Hammond 11/18/2014 1:56:15 PM

Good Example of what Total Care Cost Improvement could have been obtained
had other departments been involved from the beginning of the admission.

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by Gracie Makumbi 7/5/2014 12:47:35 PM

Unfortunately this sort of case happens often in care units, please lets join together
and make patient safety a priority in our hospitals. Gracie Makumbi

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by Ali Khan Khan Zaheed 5/15/2014 12:05:12 PM

that's why we always say patient centered care This is missing here.

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by Karen Kennedy 5/5/2014 12:39:57 PM

Thank you for posting this. It is helpful for medical staff to be fully aware of all
available aspects of patient signs, treatment and post-treatment.

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by Melissa Urquhart 4/7/2014 4:39:55 PM Page 3 of 4
Institute for Healthcare Improvement: An Extended Stay 11/2/15, 5:51 PM

1) not being put on DVT prophylaxis and not being started on levetiracitam. 2) lack
of stream lining, lack of med rec protocol on admission 3) responsive staff 4) give a
recap of what happened and open up the floor for ideas on preventing future
errors, elect a team with to put those ideas into action

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by Hope Di Piazza 10/26/2013 12:54:44 PM

Perhaps a DVT prophylaxis program as part of a standard admission set which
includes non-pharmaceutical elements such as ambulation, compression hose,
and/or sequential compression devices would be a good "safety net". This could
include a nurse order to ask physician for anticoagulation orders if they haven't
been addressed, but at least the other elements would already be in place. I also
might want to explore why a nurse would not administer a medication simply
because it's not there. Were there staffing issues that caused her to be too busy to
follow through on obtaining the missing medication? And of course, why was it
missing (unavailable) to begin with?

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by Ross Hilliard 9/11/2013 4:49:47 PM

Don and Tanya, thank you for your comments! --- The medication issue that you
both touch on is key to this case. Id challenge you to think about why else the
medication might have been marked as it was without additional follow up. Did the
nurse notify a physician that simply didnt respond? Was it difficult to know which
resident or intern was responsible for the patient given the number of handoffs? In
the setting of this confusion, was it easy for a mistake to happen? Also, was the
nurse familiar enough with the medication to understand its critical importance for
the patient (as compared to a simple stool softener where a missed dose has far
less impact)? --- Regarding a DVT prevention program, its important to have, but
what if in this case the program existed but had been ignored or a work-around
was in place to avoid placing the orders? How do hospitals and others providing
care implement prevention programs that are easy to use and accepted by the
front-line clinicia

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by Don Krueger 9/6/2013 1:34:53 PM

Was the culture of the unit such that it prevented the primary nurse from making
the necessary notifications? Was it acceptable to not administer a medication with
"unavailable" as a reason?

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by Tanya Perdue 9/1/2013 12:57:52 PM

The charge nurse should have been notified of the medication that was not
available, She could have contacted the pharmacy to bring it stat. They should
have a preventative DVT program in place.

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