University of British Columbia Canada Records Discussion

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The Unfortunate Admission
Student Name
Author Note
This paper was prepared for Health Care Operational Decision Making
The Unfortunate Admission
This research paper will analyze, identify the errors and issues, conduct a root cause
analysis and give a recommendation to the fictitious case study called “The Unfortunate
Admission”. This analysis will bring awareness to hospitals so that issues like these are not
Jane Nagel is an 18 year old female with a history of SLE Lupus, which had been
diagnosed two years previously. For reasons of socio-economic origins, Jane was not very
compliant with the medical treatment recommended by her treating Rheumatologist. For the
admission of this case study the author will give an account of the events.
On the first day, Jane Nagel arrives at the Emergency Room with a several complaints.
Dr. Hall decided to admit her overnight. Once admitted, Jane was assessed by the on call intern
Dr. Thompson and overviewed by the attending Physician Dr. Cash. They both concluded a
diagnosis of a Lupus flare. Dr. Thompson wrote the order for Plaquenil and Prednisone at 9:30
p.m., but the Pharmacist decided not to process both orders due to lack of clarity. On the second
day, Jane’s lab results were consistent with infection and Lupus flare. Her vital signs and
symptoms continue to decline due to inefficient treatment, miscommunication among staff and a
faulty EHR system among other errors. On the third, she was discharged and readmitted the
same day. After her readmission her health status declined leading to her death seventeen hours
after her initial discharge (Baum, Fjone, Potthoff, Riley, & Unden, 2008, p. 1-8).
Errors/ Issues
There were many errors made in this case study. These errors caused to some of the main
issues that led Jane’s death. The main issues were an unclear hierarchy for decision making,
physician burnout, a faulty EHR system, and an incorrect use of resources and protocols. For the
sake of simplicity the author will focus on the issues in the order of importance.
A Clear Decision Making Hierarchy
The employees did not have a clear medical professional hierarchy at that hospital. The
LPNs were reporting to on call interns instead of an RN or the attending physician. Pharmacist
were taking it upon themselves to no fill prescriptions instead of getting clarification from a
physician. The attending physician was not checking on the interns work and only relying on
their verbal reports (Baum et al., 2008, p. 1-8).
Physician Burnout
Dr. Thompson was not fully focused, was forgetful, and did not prioritize the issues
correctly. The case study points out that during the time Dr. Thompson was treating Jane, he was
the on call intern. This means he had already done his regular shifts and had been called back to
the hospital to work overtime. His lack of focus and forgetfulness led to Jane not getting the
necessary medications on time and being wrongfully and prematurely discharged (Carter, 2012).
Faulty EHR System
The attending intern was not fully trained on the EHR system. This led to the intern not
seeing the pending lab results before discharging the patient. The EHR system failed to produce
an alert for abnormal or pending labs, unfilled prescriptions, recent orders given by another
provider and a record of who accessed the patient’s records and when. Also, the EHR system
allowed the discharge of the patient while there were still lab results in process. Another error
was that Jane’s complete medical records were not in the EHR system; only the last nine months
(Baum et al., 2008, p. 1-8).
Correct Use of the State and Hospital Resources and Protocols
Due to Jane’s history and socio-economic background, she is considered a self-neglected
patient with a lack of transportation. She was a minor in foster care when she was diagnosed with
Lupus and she should had been under the care of a social services. There is no record of her
treating Rheumatologist following up on her missed appointments, or any records of the patient
being offered social services from the state (“self-neglect”, n.d.). Another error was that even if
the hospital could not offer Jane transportation, they should have called and paid for an
ambulance to pick her up at the sober house. The main error under this issue category is that Dr.
Thompson discharged Jane prematurely. He disregarded Jane’s complaints and did not check for
pending orders or exams results, and he discharged her based on his opinion of a lengthy stay or
maybe just to comply with what could have been the hospital’s turn over protocol. Protocols
sometimes need to be overridden on a case-by-case basis (Baum et al., 2008, p. 1-8).
Root Cause Analysis
The root cause analysis will identify the causes and effects of each of the issues that led to the
negative outcome of this case study.
A Clear Decision Making Hierarchy
All health care facilities need to have a clear hierarchy and ranking based the employee’s
licensure and experience, and employees need to be well informed about such a hierarchy. The
cause of Jane’s inadequate treatment was that employees were not reporting to their immediate
supervisor for orders, overriding orders, or for order clarification. The attending physician who
had the power and experience above any other employee on that shift, did not review the intern’s
work and only relied on his verbal reports. This led to all the wrong and/or inexperienced people
making the wrong “life or death” decision over Jane’s case. Just like in the armed forces, ranking
is clear and enforced because lives can depend on that one swift and correct decision made by
the appropriate person in charge.
Physician Burnout
It cannot be determined exactly the amount of overtime Dr. Thompson worked.
Although, based on the information given, it is calculated that Dr. Thompson exceeded thirteen
hours of overtime in a period of three days, with breaks as little as ten hours in between shifts. It
is common for some physicians to work over sixty hours a week with very little breaks in
between. Although physicians train for these type of schedules during their residency years, it
has been prove that inadequate amounts of rest can cause a lack of mental focus (Carter, 2012).
Dr. Thompson was an intern; this means he was in training, learning that specific specialty and
still getting used to the arduous shifts the specialty requires. This provides all more reason for
which the attending physician, Dr. Cash and Dr. Wells, needed to be doing checks and balances
on all of Dr. Thompson’s work. Had the attending physicians reviewed Dr. Thompson’s work, or
had he not been over worked, there would had not been such irreversible disruption in Jane’s
care and treatment, and her life could had been saved.
Faulty EHR System
One of technology’s purposes is to prevent human error. A faulty EHR system defeats
that purpose. In this case, the EHR system should have had all of Jane’s medical history, an alert
for abnormal or pending labs, or unfilled prescriptions, and not allow the physician to discharge
the patient until all orders have been completed, checked and finalized by the discharging
physician. Again, along with all the issues previously mentioned and a faulty EHR system, this
caused the perfect storm for an inexcusable poor treatment, which led to Jane’s death.
Correct Use of the State and Hospital Resources and Protocols
The hospital did not make a correct use of its own resources nor the resources offered by
the state for that matter. Jane was not under the supervision of a social services worker. This
caused her to not have the appropriate transportation to follow up consistently with her
Rheumatologist and take care of her condition appropriately. Lack of constant treatment of her
Lupus caused for her condition to flare up and worsen. Also, as it was discovered that Jane had
come back to the hospital for being wrongfully and prematurely discharged, the hospital should
have sent an ambulance to bring her back to the hospital. Seven hours between readmission and
the initial discharge was precious time that did not need to be wasted and could have saved her
Based on the tragic outcome of this case study and to prevent incidents like these from
happening again in the future, the author recommends:
The Chief medical doctor of each department in the hospital needs to create a clear
hierarchy of all or any given shift. Place visible posters demonstrating such a hierarchy and the
responsibilities of each member in the hierarchy for all employees to refer to when needed. Staff
each shift correctly, and do not just rely on the interns doing the job of the doctors or the LPNs
doing the job of the RNs.
The IT department needs to sit down with management and employees that have direct
contact with patients to work on suggestions on how to make the EHR system fail proof. If the
IT department cannot make such drastic changes to the system, the hospital needs to look into a
different brand of EHR software that can meet the hospital’s needs. Also, all personnel need to
be fully trained on the EHR system during the hiring process.
Doctors and nurses need to be better trained on identifying patients that need social
services and promptly put that patient in contact with a social worker. Once a patient is with
social services, the patient becomes the government’s responsibility. This increases the chances
of a patient’s better treatment outcome and decreases the overall chances of the hospital having
to carry over the cost of treatment.
The hospital’s management needs to remember that in a case of emergency or a potential
law suit, the patient’s wellbeing comes first, and they should go the extra mile to use any
available resources or use extraordinary measures, regardless of the cost. Always consider:
People come before money.
This research was based on a case study about Jane Nagel. A self-neglected young girl
with no resources to treat and control her Lupus. She arrived to hospital quite ill. An arrange of
mistakes and issues arise during her three day stay as an inpatient. All off the issues and errors
made in this case, costed this young girl’s life. This was a very tragic and sad case. The author
thinks of it as a Murphy’s Law study case. Anything that could had gone wrong; went wrong.
The author goes over the case and identified four main issues and errors made, conducts a root
cause analysis of each issue and offers several recommendations to fix these issues. The author’s
goal with this research is to bring consciousness to healthcare facilities so that issues like these
do not become recurrent.
ANA. (2018, December 20). Retrieved from American Association for Clinical Chemistry
Baum, K., Fjone, A., Potthoff, S., Riley, W., & Unden, D. (2008). The Unfortunate Admission.
Minneapolis, MN: University of Minnesota.
Carter, S. B., Psy.D. (2012). Where Do You Fall on the Burnout Continuum? Psychology Today.
Retrieved from
Dagan, R., Hall, C.B., & Menegus, M.A. (1985). Atypical bacterial infections explained by a
concomitant virus infection. American Academy of Pediatrics, 76(3), 1-411. Retrieved
Lupus Medicines – Hydroxychloroquine. (n.d.). Retrieved from
Scalpel, S. (2013, August 26). Who’s At Fault If a Patient Doesn’t Follow Up? Retrieved from
Physician’s Weekly website:
Self-Neglect. (n.d.). Retrieved from Washington State Department of Social and Health Services

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