Question: Ellie Was An 85-year-old Resident Who Was Returning To The Nursing Home On 11/5/18 From The Hospital Following A Left Hip Fracture. She Had An ORIF Done. Before Her Fall, Ellie Had Been A Resident Of The Nursing Home For Only A Week When She Sustained The Fracture. She Has A History Of Congestive Heart Failure With Frequent Exacerbations. Admission …

Ellie was an 85-year-old resident who was returning to thenursing home on 11/5/18 from the hospital following a left hipfracture. She had an ORIF done. Before her fall, Ellie had been aresident of the nursing home for only a week when she sustained thefracture. She has a history of congestive heart failure withfrequent exacerbations. Admission vital signs were BP 132/76, HR82, RR 18.

Ellie’s transfer form from the hospital included an order forLasix as well as several new medications. Lasix was part of heroriginal nursing home medication list before being transferred tothe hospital. All medication orders from the transfer form werere-written on the new Medication Administration Record (MAR), butthe old MAR from the previous stay was not removed. When the nursechecked the new orders, she mistakenly interpreted the new Lasixorder on the MAR as an unintentional duplication in transcriptionand yellowed out the line on the MAR. She was interrupted to take aphone call and did not complete the process of checking the neworders. She asked another nurse to complete the process. The secondnurse completed double-checking the orders and noted the old MARwas still present. She removed the old MAR and let the first nurseknow she had completed the task.

The nurse who was passing medications noted the line for Lasixhad been yellowed out, which she interpreted to mean the medicationwas discontinued. She was the same nurse who passed the medicationson the unit for three days in a row. On 11/7/2018, havinginterpreted that the medication was discontinued earlier, removedthe Lasix from the medication cart to be sent back to the pharmacy.It was picked up to return to the pharmacy on 11/8/2018.

Ellie was weighed on November 8th with a noted 3 lb. weightincrease from admission. The weight was recorded in her chart withan indication that a call would be placed to Ellie’s physician. Nonew orders were recorded following that entry. On 11/09/18, at 2a.m., Ellie was noted to be having extreme difficulty breathing.She had +4 pitting edema, BP was 190/110, HR 120, RR 28. Her lungswere assessed and were moist with crackles throughout. Theattending physician was called. The physician ordered Ellie to betransferred back to the hospital. While awaiting the ambulance,Ellie went into cardiac arrest and could not be resuscitated.

1. what system process improvements that might reduce thelikelihood of similar errors in the future? (in 400 words