Case Study A
Karen Viani was newly diagnosed with congestive heart failure one month ago. Her primary physician prescribed a number of medications: a beta blocker to slow her heart rate, Lasix to treat the fluid overload, and digoxin for control of her symptoms. She also takes a potassium supplement. Ms. Viani is 76 years old, slim, and lives with her pet dog, Alfredo.
She was hospitalized on Friday at noon at Mesa Valley Hospital, a 60-bed acute-care facility. This was after seeing her primary doctor for increased shortness of breath and after gaining four pounds in 24 hours. The hospitalist ordered a one-time dose of Lasix 20mg IV on admission followed by a lab order to check electrolytes in one hour.
Recent hospital patient safety survey results identified some areas of strength and weakness. Strong positive responses were in the categories of organizational learning and continuous improvement at 78%; teamwork also scored a high 80% positive response. Areas with potential for improvement were staffing at a positive response rate of 25% and non-punitive environment and safety culture had a positive response rate of 20%.
The nurse responsible for care of Ms. Viani was very busy. She gave the Lasix three hours after Mrs. Viani arrived and after the lab had drawn the blood for the electrolytes. When the hospitalist arrived at 1630, she noted the lab report indicated that the potassium level was low. The hospitalist assumed that the blood was drawn after Ms. Viani had received the Lasix.
The hospitalist ordered another Lasix 20 mg IV. The evening nurse noted the order at 1700 and gave the Lasix before dinner.
During the evening mealtime, Ms. Viani suddenly felt light-headed, tried to reach the call bell that was on the bedside table, and fell on the floor. Ms. Viani sustained a small laceration on her forehead and a sprained right wrist, and then became quite disoriented and lost consciousness for a few seconds. The rapid response team (RRT) was notified and by the time the team arrived, Ms. Viani was lucid and was complaining of pain in her right wrist. The hospitalist ordered in the patient’s record that an incident report needed to be filed as the nurse made a medication error. The hospitalist has professional liability insurance as a condition of her employment at Mesa Valley. The nurse does not.