Summary Post Instructions:
Go to the Institute of Healthcare Improvement (IHI) website at www.ihi.org (https://www.ihi.org/) Links to an external site. and Click on the “Resources” tab, then click on the “Case Studies” tab.
Choose a case study from the many listed case studies listed on the two pages.
Go to the I’ve Got This One – Discussion Assignment 2 discussion forum.
This is a first-come-first-claimed assignment.
Read all of the posts first.
If your chosen case study has already been claimed by another student, you must choose another.
After you verify that you are the first person to choose your case study, post a message simply stating which case study you have chosen to research.
3. Read your case study
4. Write a summary and include the following:
A one-paragraph summary of what happened in your case study.
A one-paragraph summary telling us, in your opinion, what went wrong and how it could have been prevented.
Neatly type your assignment, including a heading with your name, date, and and the case study title into a WORD document and save it.
EXAMPLE:
Case Study: “An Extended Stay”
What happened in this case study?
A 64-year-old man with a history of seizures, chronic obstructive pulmonary disease (COPD), and taking several medications, came to the emergency department (ED) because he was wheezing and having trouble breathing. The examination showed he had worsening signs of his COPD. They performed a chest x-ray and routine blood tests, then admitted him to the hospital to treat his COPD. He was improving until the third day when he complained of leg pain. An ultrasound revealed a blood clot. A resident then checked his chart and found no orders for blood thinners, which is standard treatment for preventing blood clots. On the eighth day, a member from housekeeping, found him on the floor having a seizure. He had a CT scan. They reviewed his chart and discovered he had not received his anti-seizure medication earlier that day, only a notation that it was not available and not administered. They restarted his medication and he suffered no permanent harm but did end up staying 10 days in the hospital.
What went wrong and how could it have been prevented?
In my opinion, quite a few things went wrong. There were not orders for him to receive blood thinners or other clot prevention measures, while lying in bed after being admitted. As a result, he developed a clot. Later, he was not given his usual anti-seizure medicine which resulted in him having a seizure and falling out of bed. He had to have a CT scan because no one saw him fall. There needs to be some sort of medicine review protocol at admission and throughout the patient’s hospital stay. It should include alerts if medicines were not given. There were several errors plus a lack of communication that contributed to needing extra tests and a prolonged hospital stay, but fortunately this did not end in the death of a patient.
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