patient safety comic book
TRANSCRIPT
Patient SafetyComic Book
Theresa Maatman, MD
Kathlyn Fletcher, MD
Its about midnight on your call night. You are trying to get
some rest when your senior resident pages you to the
team room.
Its about midnight on your call night. You are trying to get
some rest when your senior resident pages you to the
team room.
• Amitriptyline is a fall risk for elderly patients
• Multiple Benzodiazapines
• Multiple hypnotic agents• Diuretic use in elderly• Diuretic use with kidney
disease• NSAID use with kidney
disease• Failure to thrive is
probably not straight forward
Review the picture on the prior page to answer the following questions.
1. What safety concerns do you have?
2. What orders or plans would help decrease risk to the patient?
Review the picture on the prior page to answer the following questions.
1. What safety concerns do you have?
2. What orders or plans would help decrease risk to the patient?
Falls from hypnotic medicationsDelirium from polypharmacy ageHypoglycemia from insulinKidney injury from diuretic and NSAIDs
Delirium orders to reduce deliriumClose monitoring of insulinDiscontinue HCTZ and NaproxenDiscontinue Benzos and monitor for withdrawalConsider change of amitriptylineBeer’s list
Your senior puts in some basic orders while you review the
chart. Afterwards, you head to the his room. The nurse is
outside his room when you arrive.
Your senior puts in some basic orders while you review the
chart. Afterwards, you head to the his room. The nurse is
outside his room when you arrive.
• ID band not on the patient
• Common last name resulting in a medication error potential
• Allergy to cephalosporin
• Absent isolation equipment
• Empty hand sanitizer
Review the picture on the prior page to answer the following questions.
1. What new and ongoing patient safety concerns do you see?
2. What else should be done to prevent spread of C diff?
Review the picture on the prior page to answer the following questions.
1. What new and ongoing patient safety concerns do you see?
2. What else should be done to prevent spread of C diff?
PPE Hand sanitizer or hand washingName alertsChecking multiple patient identifiersMed reconciliation
PPEWash hands on leaving room
Patient agrees to treatment for his C diff. His wife, on the
phone, requests an evaluation of his swallowing. But when
asked, they both decline resuscitation or intubation for him.
Patient agrees to treatment for his C diff. His wife, on the
phone, requests an evaluation of his swallowing. But when
asked, they both decline resuscitation or intubation for him.
• Walker, phone and call light, glasses out of patient reach
• Sitting up watching TV in the middle of the night
• Liquid on the floor• No shoes or socks
on patient
Review the picture on the prior page to answer the following questions.
1. What factors could put the patient at risk for delirium?
2. What new factors pose a safety risk to the patient?
Review the picture on the prior page to answer the following questions.
1. What factors could put the patient at risk for delirium?
2. What new factors pose a safety risk to the patient?
Day night reversal and sundowningGlasses not available for patient
Fall risk: walker, phone, call light all out of reachLack of non skid shoes or socksLiquids on the floor putting at risk of falling
The next day after a long shift you find your colleague who
will be covering for you while you are post call. You bring
him your sign out sheet.
The next day after a long shift you find your colleague who
will be covering for you while you are post call. You bring
him your sign out sheet.
• Concerning vital signs
• No verbal hand off• Vague language• Non consistent• Full diet despite
swallowing concerns
Review the patient information on the prior page to answer the following question.
1. What are the components of a high quality hand off?
2. What are the threats to a high quality hand off in this situation?
Review the patient information on the prior page to answer the following question.
1. What are the components of a high quality hand off?
2. What are the threats to a high quality hand off in this situation?
Clear language- not using “tomorrow”Up to date- sign out is consistent with the chartGuidance- Offering If… than… statementsVerbal and written componentsDedicated time to sign out in person
Vague languageNo guidanceInconsistentNo verbal component
The following day when you return you find out Mr. Lee
aspirated over night and now is requiring oxygen. He is also
confused about why he is in the hospital.
The following day when you return you find out Mr. Lee
aspirated over night and now is requiring oxygen. He is also
confused about why he is in the hospital.
• Sharp on the counter
• Restraints in place and one is improperly tied (on a movable part of the bed with no quick release
• Bed height at max• Catheter in place• Bed brake off• Oxygen improperly
place on face so is a choking risk
• All 4 rails are in place
Review the patient information on the prior page to answer the following question.
1. What factors put the patient at risk of further delirium?
2. What new factors pose a safety risk to the patient
Review the patient information on the prior page to answer the following question.
1. What factors put the patient at risk of further delirium?
2. What new factors pose a safety risk to the patient
RestraintsCatheter
Fall risks: Bed height, bed brake, all 4 rails in placeSharps on the counterOxygen tube posing a choking risk
Review the whole case to answer the following questions.
1. What were preventable factors in this adverse outcome?
2. In what ways could communication play a role in improving this case?
Review the whole case to answer the following questions.
1. What were preventable factors in this adverse outcome?
2. In what ways could communication play a role in improving this case?
Communicate with Attending deterioration of patientCommunicate with family poor outcomesVerbal sign outsDiscussing plans with nurses
Delirium preventionReduction of aspiration risk