Rose is a 79- year- old woman with hypertension, arthritis,diabetes, and chronic periodontal dental problems. She lives alonein a trailer in a rural county 40 miles away from a major city. Shehas no family and does not drive. Her 70- year- old neighbor, Fred,lives about 10 miles down the road and checks on Rose weekly. Hetakes Rose to doctor appointments and helps with weekly errands.Rose cooks, pays bills, and does light housekeeping. She especiallyenjoys the company of her television. She has difficulty hearingthe telephone. She sits in a recliner 4 to 5 hours per day with theheels of her feet against the calf support of the recliner. Shereceived a check up from her physician a year ago. Rose scored 28/30 (minimal impairment) on the Mini- Mental State Examination.
At that time, she was diagnosed as having a stage II pressuresore on the dorsum of the right heel. The doc-tor reminded Rose tochange positions often and to keep pressure off the heel. Rose didnot keep her scheduled follow- up appointment with the doctor amonth later. Rose decided to apply elastic stockings (T. E. D.hose) last week . The stockings were previously issued a year agofor management of lower- extremity edema. Because of joint pain inher hands and fingers associated with arthritis and difficultyapplying the hose, she decided to leave the hose on. She slept inthe hose for 7 days. This week Rose began to experience somediscomfort in her foot with weight bearing. Fred stopped by to dropoff the groceries and noticed some bleeding around the heel. Rosetold Fred that she has been taking some Darvocet that she had leftover from a dental abscess 3 years ago. She also complained ofdizziness and fell in the bathroom yesterday.
Fred decided that her problems were severe enough to take her tothe emergency department at the local hospital. The T. E. D. hosewere removed, and the wound was cultured. The culture revealedmethicillin- resistant Staphylococcus aureus colonization. She wasadmitted to the hospital for a 3- day stay. A team conference(including Rose, Fred, Rose’s physical therapist, her occupationaltherapist, her social worker, and her pharmacist) was called todevelop her discharge care plan. The team’s recommendationswere forwarded to Rose’s physician.
To Be Included In Your Paper: CaseStudy Questions:
1. Was harm incurred? Was it likely preventable? How?
2. Identify two system failures in this case.
3. What are the responsibilities of the healthcare professionalsin this case?
4. What are the responsibilities of the patient in thiscase?
5. What is needed to develop a culture of safety duringtransitions/ handoffs from one area of care to another?
Rose is a 79- year- old woman with hypertension, arthritis,diabetes, and chronic periodontal dental problems. She lives alonein a trailer in a rural county 40 miles away from a major city. Shehas no family and does not drive. Her 70- year- old neighbor, Fred,lives about 10 miles down the road and checks on Rose weekly. Hetakes Rose to doctor appointments and helps with weekly errands.Rose cooks, pays bills, and does light housekeeping. She especiallyenjoys the company of her television. She has difficulty hearingthe telephone. She sits in a recliner 4 to 5 hours per day with theheels of her feet against the calf support of the recliner. Shereceived a check up from her physician a year ago. Rose scored 28/30 (minimal impairment) on the Mini- Mental State Examination.
At that time, she was diagnosed as having a stage II pressuresore on the dorsum of the right heel. The doc-tor reminded Rose tochange positions often and to keep pressure off the heel. Rose didnot keep her scheduled follow- up appointment with the doctor amonth later. Rose decided to apply elastic stockings (T. E. D.hose) last week . The stockings were previously issued a year agofor management of lower- extremity edema. Because of joint pain inher hands and fingers associated with arthritis and difficultyapplying the hose, she decided to leave the hose on. She slept inthe hose for 7 days. This week Rose began to experience somediscomfort in her foot with weight bearing. Fred stopped by to dropoff the groceries and noticed some bleeding around the heel. Rosetold Fred that she has been taking some Darvocet that she had leftover from a dental abscess 3 years ago. She also complained ofdizziness and fell in the bathroom yesterday.
Fred decided that her problems were severe enough to take her tothe emergency department at the local hospital. The T. E. D. hosewere removed, and the wound was cultured. The culture revealedmethicillin- resistant Staphylococcus aureus colonization. She wasadmitted to the hospital for a 3- day stay. A team conference(including Rose, Fred, Rose’s physical therapist, her occupationaltherapist, her social worker, and her pharmacist) was called todevelop her discharge care plan. The team’s recommendationswere forwarded to Rose’s physician.
To Be Included In Your Paper: CaseStudy Questions:
1. Was harm incurred? Was it likely preventable? How?
2. Identify two system failures in this case.
3. What are the responsibilities of the healthcare professionalsin this case?
4. What are the responsibilities of the patient in thiscase?
5. What is needed to develop a culture of safety duringtransitions/ handoffs from one area of care to another?
