In the book, \"Patient Safety for Health Professionals\" it states, \"Joan W. is
ID: 125078 • Letter: I
Question
In the book, "Patient Safety for Health Professionals" it states, "Joan W. is a registered nurse who has worked on a surgical unit for 10 years. Dr. B is a surgeon whose patients come to this unit for postoperative care. Joan has never known Dr. B. to make an error or had any reason to question any of his orders. One day Dr. B. came to the unit at 7:30 p.m. after an especially long and hard day in the operating room. He looked very tired and said he thought he was getting the flu. He wrong a long set of orders for a postoperative hip fracture patient, but he did not include an order for Lovenox, as he usually did. Joan did not notice the omission until 11:30 p.m. She wondered whether he could have forgotten the order because he was so tired and possibly sick, but he did not want to call him because it was so late. She told herself that there are contraindications to Lovenox and that Dr. B probably had a good reason for not ordering it. Joan saw Dr. B in the morning as he made his 6 a.m. rounds before surgery, but by that time, she was so tired she forgot to ask about the Lovenox. Tom F. is a junior nursing student asigned to care for the patient starting at 7 a.m. the next morning. When he had been at the hospital the evening before to gather information for his plan of carem the patient's orders were not available yet. When he saw the orders in the morning, he wondered why there was no order for deep vein thrombosis (DVT) prevention because it was included in the clinical practice guideline. When he took the report from Joan W., he asked her. This reminded her that she meant to ask Dr. B., and, before she left, she called down/to the operating room and had a nurse ask Dr. B about it. He responded that he must have forgotten it, gave a verbal order, and the patient recieved the first dose of Lovenox on the first postoperative day as the protocol specified. The patient recovered well and had no evidence of a DVT. Dr. B. told Joan later that he was so glad she had reminded him about the need for a Lovenox order.
1. If Tom had not asked about the omission and the patient developed a DVT, whose fauly woudl it have been?
2. If Dr. B. had previously rebuffed Joan for asking him questions about omissions in orders, might that have prevented her from calling him?
3. If Joan had told Tom that she was not going to ask because she knew Dr. B well and that he never made mistakes, what should he have done?
4. What system features could have been used to make sure that an order like this was not forgotten?
5. Would it be appropriate to report this event as a near miss? Is this just an everday occurence?
6. What other professionals might have been in a position to catch this error of omission?
Explanation / Answer
If Tom had not asked about the omission and the patient developed a DVT, whose fault would it have been?
If the patient would have suffered DVT, the negligence would be first directed to Dr.B.
If Dr. B. had previously rebuffed Joan for asking him questions about omissions in orders, might that have prevented her from calling him?
No. Even if the rebuffing would have taken place, it is Joan’s duty to call him because all of them are responsible for the patient’s condition and negligence can cause the patient’s life.
If Joan had told Tom that she was not going to ask because she knew Dr. B well and that he never made mistakes, what should he have done?
Tom still must have proceeded to ask Dr. B as protocol is more important for patient’s life.
What system features could have been used to make sure that an order like this was not forgotten?
A reminder or check list for Fracture conditions would help the doctor and the team to keep a check to avoid omissions.
Would it be appropriate to report this event as a near miss? Is this just an everyday occurrence?
It should be reported / documented as to avoid such misses in future as part of the hospital guideline protocol.
What other professionals might have been in a position to catch this error of omission?
The technician, the record keeper, shift nurse change would be able to help catch the miss.
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