4/30/2023 0 Comments Failure to due care![]() ![]() ![]() While being transferred, she had a pulseless electrical activity arrest in the setting of massive hematemesis, and she died despite maximal efforts. The intensive care unit (ICU) team consulted at the bedside and made plans to transfer her to the ICU. Bedside evaluation revealed she was hypotensive (blood pressure 75/45 mm Hg), tachycardic (heart rate 130 bpm), and confused. Laboratory results were reviewed at 6:00 AM and showed her hemoglobin had dropped to 5.8 g/dL, and her creatinine had risen to 4.5 mg/dL. She was given intravenous fluids overnight but received no specific treatments. Stat labs were ordered but not reviewed until the following morning. The gynecology resident evaluated the patient and found her to be confused and complaining of abdominal pain. Later that night at 2:00 AM, she had another episode of hematemesis. ![]() Despite the hematemesis, the rivaroxaban was continued. No laboratory values were checked, and there were no urgent interventions. Her vital signs were normal, and she was given intravenous fluids. At 7:00 PM, she had an episode of hematemesis (bloody vomit). Throughout the day, her severe abdominal pain and nausea continued. The next morning, her hemoglobin level was 7.5 g/dL and her creatinine had increased from a baseline of 2.1 mg/dL to 3.1 mg/dL. The consulting cardiology service ordered medications to control her heart rate and initiated rivaroxaban, a systemic anticoagulant, for her atrial fibrillation. She was moved to a telemetry unit and cardiology was consulted. When she had persistent severe pain later that day, her heart rate was 145 beats per minute (bpm), and she had new-onset atrial fibrillation. The following morning, she complained of severe abdominal pain with nausea, which the gynecology team attributed to postoperative pain. She was given a transfusion of two units of packed red blood cells but not evaluated by a provider. A postoperative hemoglobin check showed a drop from 9.5 g/dL before the procedure to 6.8 g/dL. Because she had relatively low blood pressures during the operation and slightly more bleeding than expected, she was admitted to the inpatient gynecology service for monitoring. Develop a baseline understanding of human factors research.Ī 72-year-old woman with a history of systolic heart failure, hypertension, and chronic kidney disease who was healthy and active at baseline was admitted for an elective dilatation and curettage for postmenopausal bleeding.Appreciate the ongoing areas of scientific inquiry into the prevention of failure-to-rescue events.Identify the main contributors to failure-to-rescue events. ![]()
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