This report is an analysis of the events and contributing factors that lead up to the death of six year old Samuel at Grantham Regional hospital on the 17th of September 2010. Samuel died in the HDU ward of Grantham Regional Hospital of septic shock that was brought on by Scarlet fever that led to pneumonia. This report will also explore how causal factors such as poor communication contributed to Samuel’s death could have been prevented and, what protocols, standards and safety models factor into these contributing issues. The events that lead to the death of six year old Samuel spanned over 4 days with several hospital presentations. Samuel first presented on the 14th of September 2010 when his mother, Louisa noticed a red rash over his …show more content…
At 1345 that day, Louisa returned Samuel to the hospital due to his worsening condition. Leanne took his obs while off duty and recorded them in the hospital documentation as the nurse was too busy, noting he was febrile at 29.7oC with a heart rate of 158bpm and had oxygen sats at 98%. Samuel was admitted under Dr. Redfern who order a chest x-ray (CXR) and a midstream urine (MSU). The CXR was taken at 1640 but was left un-reviewed by the radiologist till the 16th of September. Dr. Camden had reviewed the CXR under the instruction of Dr. Redfern before discharging Samuel. Dr. Camden recorded that there were no remarkable findings on the scan. Samuels MSU found slightly elevated Specific Gravity of 1030 and normal pH of …show more content…
Ashfield at 1200hours. He noted that Samuel was febrile, with a respiratory rate of 39, dry lips, strawberry tongue, poor capillary refill and had very lethargic behaviour. Dr. Ashfield wrote a letter to Grantham Hospital requesting for Samuel to be admitted to the Emergency Department with a diagnosis of Scarlet fever. Samuel’s ED observations report an axillary temperature of 38.3oc, heart rate 67bpm, Resp. rate 24, and SpO2 of 100%. Staff also noted Samuel had grunting on expiration. Samuel was admitted under Dr. Ingleburn (Paediatrician) at 1245 and transferred Samuel to the HDU, prescribing 1.2g IV penicillin Q.I.D accompanied by IV fluid maintenance. At 1350 hours Samuels’ heart rate was 191bpm and his respiratory rate was 62 with notable rib recession. Samuel was put on continuous telemetry with hourly observation recordings. At 1400 Dr. Dargan, the radiologist reviewed the previous CXR reporting evidence of Pneumonia. Samuel was given analgaesia at 2245 after being in pain from
Dr.Bain ordered a CT scan of Cynthia’s chest to rule out a possibility of an aneurism. Dr. Bain also did another CT scan of Cynthia’s abdomen to evaluate her liver. Additional lab work and thyroid testing was done. Around 5:00pm she was discharged with instructions to follow up with her primary care physician Leah Avera, M.D within one week. In Cynthia’s discharge summary that was signed by Dr. Pesante, states, in part, "it just seems like Cynthia’s problem may have more so been either some kind of infectious process or possibly a thyroid
I attended the Saturday Lab 1 session discussing the Denison Specialty Hospital case study. In our session, we had a through discussion into the different budget terminology. I learned about the difference between accrual and cash accounting methods, which is based on the timing of when the revenue and expenses are recognized. I also learned about responsibility centers as an organizational unit under the supervision of a manager, who is responsible for its activities and results. In addition, the manager is accountable for the budget of the department that they head. Therefore, a centralized form of management in developing the budget because it makes easier to because the information for the department budget is located
Examination revealed an oxygen saturation of 98% and blood pressure of 145/90. Oropharyngeal inspection revealed significant crowding (Mallampati class 3) with macroglossia. Chest auscultation was clear and two heart sounds were audible with nil else.
Franco was being treated by Emergency Room Doctor Greer. I saw that medical staff took a blood sample from Franco prior to administering him with an unknown dose of Fentanyl and Saline. Based on the above medications being administered to Franco, I was unable to obtain an untainted blood sample for his BAC level.
Mrs. Jones, 78 years old, arrived in the emergency department (ED) via ambulance. She was alert and oriented, but was having episodes of lost consciousness. She was put on the cardiac monitor and her vital signs were obtained. Her cardiac rhythm was normal. Her vital signs were as follows: Temperature 97.3°F, Pulse 43, respirations 26, blood pressure 100/58 and O2 saturation of 94% on room air. Additionally, Mrs. Jones was vomiting and had 2 loose, incontinent stools. She was pale, cool to touch and diaphoretic. Auscultation of her lungs revealed expiratory wheezes.
When Sir Gerry Robinson first came to Rotherham General Hospital which had already got into troubles of intolerable long waiting list, low working willingness and substantial financial shortages, he found that the situation in the hospital was even worse than his imaginations. These facts, such as stressed relationships among staff and meaningless managements of the top manager, further resulted in the self-interest protections of hospital staff. Furthermore, the wastes everywhere, for example, vacant wards and buildings, and the empty timetables on Friday afternoons due to people’s unwillingness to bear duty, heavily shocked him.
On admission, a complete physical assessment was performed along with a blood and metabolic panel. The assessment revealed many positive and negative findings. J.P. was positive for dyspnea and a productive cough. She also was positive for dysuria and hematuria, but negative for flank pain. After close examination of her integumentary and musculoskeletal system, the examiner discovered a shiny firm shin on the right lower extremity with +2 edema complemented by severe pain. A set of baseline vitals were also performed revealing a blood pressure of 124/80, pulse of 87 beats per minute, oxygen saturation of 99%, temperature of 97.3 degrees Fahrenheit, and respiration of 12 breaths per minute. The blood and metabolic panel exposed several abnormal labs. A red blood cell count of 3.99, white blood cell count of 22.5, hemoglobin of 10.9, hematocrit of 33.7%, sodium level of 13, potassium level of 3.1, carbon dioxide level of 10, creatinine level of 3.24, glucose level of 200, and a BUN level of 33 were the abnormal labs.
In our organization we have had many revisions to our safety process. Originally, it was at our hospital that the 1996 well known “Willy King” incident, about the amputation of the “wrong” leg occurred. As a response to the incident, we were required to develop a root-cause-analysis and develop a plan to avoid similar situations in the future. We were one of the first hospitals to establish a “safety process” in the surgical environment. Through inter-disciplinary collaborati...
The purpose of his article was to find a better way to prevent healthcare-associated infections (HCAI) and explain what could be done to make healthcare facilities safer. The main problem that Cole presented was a combination of crowded hospitals that are understaffed with bed management problems and inadequate isolation facilities, which should not be happening in this day and age (Cole, 2011). He explained the “safety culture properties” (Cole, 2011) that are associated with preventing infection in healthcare; these include justness, leadership, teamwork, evidence based practice, communication, patient centeredness, and learning. If a healthcare facility is not honest about their work and does not work together, the patient is much more likely to get injured or sick while in the
Safety is focused on reducing the chance of harm to staff and patients. The 2016 National Patient Safety Goals for Hospitals includes criteria such as using two forms of identification when caring for a patient to ensure the right patient is being treated, proper hand washing techniques to prevent nosocomial infections and reporting critical information promptly (Joint Commission, 2015). It is important that nurses follow standards and protocols intending to patients to decrease adverse
E. Coli 0157, written by Mary Heersink, is a nerve-racking, adrenaline-filled story of a mother's experience with a then unknown deadly bacteria. The book brings up many reactions in its readers, especially the questioning of the practice of doctors in hospitals. The reader's knowledge base of scientific procedures in emergency centers was widened as well as the knowledge of how to the human body reacts to different agents in its system.
Dr. Murray, the chief resident who arrived around 8:00pm, charted Lewis’ heart rate as normal and noteds a probable ileus; however, nursing documentation at the same time recorded a heart rate of 126 beats per minute (Monk, 2002). Subsequent heart rates at midnight and 4:00am arewere charted as 142 and 140 beats per minute respectively without documented intervention (Monk, 2002 ). On Monday morning Lewis noted that his pain suddenly stopped after being very constant and staff charted that they were unable to get a blood pressure recording in either arm or leg from 8:30-10:15am despite trying multiple machines (Monk, 2002; Solidline Media, 2010).
Patient safety must be the first priority in the health care system, and it is widely accepta-ble that unnecessary harm to a patient must be controlled.Two million babies and mother die due to preventable medical errors annually worldwide due to pregnancy related complications and there is worldwide increase in nosocomial infections, which is almost equal to 5-10% of total admissions occurring in the hospitals. (WHO Patient Safety Research, 2009). Total 1.4 million patients are victims of hospital-acquired infection. (WHO Patient Safety Research, 2009). Unsafe infection practice leads to 1.3 million death word wide and loss of 26 millions of life while ad-verse drug events are increasing in health care and 10% of total admitted patients are facing ad-verse drug events. (WHO Patient Safety Re...
The patient has high temperature-sign of fever, a very fast pulse rate (tachycardia), and chest wheezing when listened to using a stethoscope (Harries, Maher, & Graham, 2004, p.