New THE CENTER FOR CASE MANAGEMENT Definition Karen Zander RN, MS, CMAC, FAAN: Editor Careless Care: The Slippery Slope ONLINE EDITION Down Safety Mountain By Sue Wilson, Director, Consulting Support Services The Center for Case Management Prologue1 Ensuring patient safety is at the forefront of initiatives in health care, seemingly as huge an endeavor as a mountain to be scaled. Safety is not the peak, however; it is actually far down the slippery slope. At the peak is the connectivity of the caregivers to the work itself. But when people are over- (or under-) stressed, the next element that disappears down the slope is empathy. They just don’t care about the situation or person in front of them; i.e. care-less care. After that, they don’t expend the energy for critical thinking and clinical inquiry, which in turn, makes them dangerous; i.e. careless care. The following true story is presented as a chance to study that slope of events. Fortunately, Sue was lucky and did not become a safety statistic or a sentinel event. However, she and her family will never be going to this hospital again, and you will soon understand why. Setting the Stage for Mistakes I am generally a person who appreciates all that is given to me, and greatly respects health care personnel. But I get migraines, and I had a bad one that lingered for days. At the end of the work day, my doctor told me it was time for a shot of Toradol and sent me to the ED at a local hospital. I’ve done this several times without incident. However, this time I got a first-hand look at the crisis with patient safety.
I checked in at 4:45 pm with the triage nurse as instructed by the sign in the lobby. Then I went to registration, where the clerk asked me if everything was “the same”, to which Ireplied, “That depends what you have in there”. My records were not accurate and trying tohelp, I asked if she wanted my insurance card, as I know from CCM that it is a crucial step. She responded, “If you want to give it to me, sure”, and proceeded to tab through the restof my information. In my experience, tabbing is easy for the clerks but disastrous for thedata base, the first place where safety becomes vulnerable. Lobby Action I sat in the lobby for an hour, with a quick visit to the triage nurse for vital signs. The woman next to me was a raving lunatic who cut her leg shaving, needed a divorce lawyer and screamed at everyone and anyone who walked by. Oh, and she needed to go shopping ASAP to buy a pair of pants just like mine. It was so bad I asked them to please take her in before me. I wondered why I was in the lobby and not the un-used dark family room which in the past has been standard operating procedure for people with migraines. Enter Room #7 By 7 pm I made it into Exam Room #7, which is supposed to be a lucky number, isn’t it? The nurse came in and asked me why I was there and what type of meds I needed. I once again told my doctor’s wish that I receive Toradol. The ED doctor came in and asked me all
At 1:30 am, another nurse came into the room to take my vital
Careless Care: The Slippery Slope
signs. Now I was mad, and asked her what the point was after
Down Safety Mountain
9 hours. She said she was just doing her job, as I watched her
write away on Chart #5! “Whoa, stop!— Do you know myname?”. She said she didn’t, and I informed her that she was
the standard questions, ordered a CT scan (eeeeeek, every case
writing on Chart #5 and this was Room #7. After she said,
management director would shriek if they heard this expense)
“Whoops, wrong room”, I told her not to touch me anymore.
and also wanted to send me for an MRI! If I had to have an MRI,
It turned out that the man in Room #5 was waiting to be
they would have had to transport me via ambulance to another
facility, which didn’t seem to enter into his thought process. I had to stop him mid-sentence and repeat myself: “I have a
migraine; I get them, it’s not a new thing—look at my records
I took my IV and went to look in the hall for someone, but no
(I have a pretty thick file); my doctor wants me to have a shot
one was around. I went back to my room to use the call button
but you guessed it, it was broken. I heard the doctor at the desk
About 45 minutes later the nurse came back with an IV and a
looking for Chart #5, and, to get the staff ’s attention to my fear
needle in hand. “So what is this?” I asked. “The IV is to stop the
and frustration, I announced that the nurse threw out Chart #5.
nausea” she told me while she put it in my arm. “But I don’t
I am not proud of this, but it shows how far I felt I had to go to
have nausea, and never said I did”. A few minutes later came
be heard. I slammed my IV bag on the desk and demanded that
the shot to my bum, and I felt funny. The nurse explained that
they take the IV out and get me home. They couldn’t find my
they gave me Dilaudid, a narcotic, so now I will need a ride
chart, because Chart #7 was in the discharge pile which I
home after the migraine goes away. Actually, it was getting
happened to notice before they did, even in my drugged state
worse as I got more stressed and angry. I had to call my cousin
to give me a ride home. That was 8 pm. Around 9:30 the nurse
Within minutes they were in my room, handing me two notes.
came back and asked if the shot had worked, which it hadn’t.
One note said not to return to work due to my injury. “What
I asked again for the Toradol, explaining that it usually works
injury?”, I asked, with the reply from the nurse “I don’t know,
and I only have needed narcotics when the Toradol doesn’t
what ever injury you came in here for”. The other note was a
help. But back she came a few minutes later with another shot
prescription for percocet, which I said I never used. She
of Dilaudid because apparently Toradol doesn’t work once
replied, “Oh, just keep it, you never know”. Then they gave me
what they called “One more shot for the road”.
Meanwhile, I was not so out of it, that I did not hear the man inRoom #5 in horrible pain, apparently from gall stones, as the
doctor worked with him and the morphine drip (so much for
I survived the 4 shots of medicine I didn’t need, but now was
HIPAA). And then there was the drunk woman across the hall
numb. My cousin Sandy got me home at 3 am and I still had
threatening to kill her dead grandmother.
the migraine. They won’t miss me, but then, they didn’t knowwho I was down there in Room #7 all night anyway. As I left the
ED, Patient #5 was being wheeled to his room and the drunk,
Around 1 am I asked if I could go home, but was told I couldn’t
being her 5th visit, was also admitted. Good luck to them, I
unless my pain was gone. I recalled a friend who put ginger ale
thought. If the ED is the gateway to the hospital, just think
in her bedpan to show that she had urinated after a minor pro-
what the rest of the care will be like. This is my story, and I am
cedure because she was ready to go home. Maybe I should lie
too? Thinking better of it, I said, “No, it is pretty much thesame, but I have been her since 5pm. I’m tired, and my cousin
is tired. The nurse responded that she would give me one more
1 From K. Zander, Editor and Principal, and Co-owner, CCM.
shot—Demerol this time—because the doctor wouldn’t let meleave unless I was pain free. Come see us as we celebrate 20 years of case management expertise and you can learn more about some of our newer services
• World Research Group – Optimizing the Role of the Physician Advisor, March 27-29, Orlando, FL (Karen Zander)
• AONE Annual Meeting and Exposition, April 20-22, Orlando, FL (Kathy Bower and Karen Zander) BOOTH 1216
• NICM/ACMA conference, April 23-26, Hollywood, FL (Karen Zander and Margaret Reid)
• CMSA Conference and Expo, June 13-17 (Donna Hopkins and Shawna Kates) BOOTH 357
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