Ms. Reid is a resident from a long-term care facility whorecently had a minor surgical procedure done at the hospital.Before surgery, Ms. Reid was ambulatory and somewhatself-sufficient. Upon return to the home, the evening nurse readsthe report from the hospital which contains the followinginformation: Vital signs, condition of surgical dressing (on lefthip), and reports that the patient has been eating well. Ms. Reidis alert upon arrival. During the night, Ms. Reid falls whenwalking to the bathroom. When you come in for the morning shift youare concerned that Ms. Reid is not able to walk as she was beforethe surgery. There are no notes about her change in status on thechart or in the shift change report. Using course material andother relevant resources, including Best Practices and Leadershipactions and standards, provide a meaningful answer to thefollowing: 1. What was the adverse event in this case? Why did itoccur? 2. Did an error occur? If so, what is the classification andwhy? 3. What safety standards require compliance in this case? 4.What documentation and communication are needed to support safetyfor Ms. Reid? 5. What safety-related actions need to be taken afterthis event? 6. How would you report this event to the patientsafety committee and the patient/family? 7. As a team leader, howwould you use this event to promote safety education with staff? 8.What recommendations for change would you make to improve a cultureof safety at the LTC facility? 9. What professional safetystandards, guidelines and laws should the staff know to ensurehigh-quality care for this patient?
