Prompt: The MHA 668 course has focused on the understanding of the role of healthcare administrators in the development and implementation of quality standards as part of the strategic planning proces
____________________________________________________________________ ____T he U nfo rtu n ate A dm is sio n Pag e 1 o f 8
T his c a se s tu dy w as p re p are d f o r t h e C LA RIO N I n te rp ro fe ssio nal C ase C om petitio n. I t w as d evelo ped a s
t h e b asis f o r d is c u ssio n i n t h e C ase C om petitio n. I n fo rm atio n i n t h is c a se i s f a bric a te d /fic titio us. A ny
r e se m bla nce t o a ny h ea lth ca re p ro vid er i s p ure ly c o in cid en ta l. N o p art o f t h is p ub lic a tio n m ay b e
r e p ro duced , s to re d i n a r e tr ie va l s y ste m , u se d i n a s p re a dsh eet, o r t r a nsm itte d i n a ny f o rm o r b y a ny
m ea ns-e le ctr o nic , m ech anic a l, p hoto co pyin g , r e co rd in g o r o th erw is e w ith out t h e p erm is sio n o f t h e
U niv ersity o f M in neso ta .
2 008 U niv ersity o f M in neso ta B oard o f R eg en ts . T he U niv e rsity o f M in neso ta i s a n e q ual- o pportu nity
e m plo yer a nd e d uca to r. T his d o cu m en t i s a va ila ble i n a lte rn a te f o rm ats . F or i n fo rm atio n, c o nta ct B arb a ra
B la lo ck 6 12 -6 2 6-7 3 79
C LA RIO N
A n I n te rp ro fe ssio n al S tu den t C om mit te e o f t h e
C en te r f o r H ea lt h I n te rp ro fe ssio n al P ro gra m s ( C H IP )
UNIV ER SIT Y O F M IN NESO TA
T he U nfo rtu nate A dm is sio n
T he d eta ils c o nta in ed i n t h is c ase w ere w ritte n a s a t e am b y
( lis te d a lp hab etic all y )
K ary n B au m , M D, M SE d
A sso cia te P ro fe sso r o f M ed ic in e
S pecia l A ssis ta n t t o t h e D ean
S ch ool o f M ed ic in e
U niv ers it y o f M in neso ta
A
ndra F jo ne, M N, C PN P
C lin ic al A sso cia te P ro fe sso r
S ch ool o f N urs in g
U niv ers it y o f M in neso ta
S an dra P otth off, P h.D .
A sso cia te P ro fe sso r a n d D ir e cto r
P ro gra m i n H ealth care A dm in is tr a tio n
S ch ool o f P ublic H ealth
D iv is io n o f H ealth P olic y a n d M an ag em en t
U niv ers it y o f M in neso ta
W
illia m R ile y , P h.D .
A sso cia te P ro fe sso r
A sso cia te D iv is io n H ead
S ch ool o f P ublic H ealth
U niv ers it y o f M in neso ta
D on U den , P harm .D .
P ro fe sso r
P harm aceu tic al C are a n d H ealth S yste m s
C olle g e o f P harm ac y
U niv ers it y o f M in neso ta
____________________________________________________________________ ____
T he U nfo rtu n ate A dm is sio n Pag e 2 o f 8
T his c a se s tu dy w as p re p are d f o r t h e C LA RIO N I n te rp ro fe ssio nal C ase C om petitio n. I t w as d evelo ped a s
t h e b asis f o r d is c u ssio n i n t h e C ase C om petitio n. I n fo rm atio n i n t h is c a se i s f a bric a te d /fic titio us. A ny
r e se m bla nce t o a ny h ea lth ca re p ro vid er i s p ure ly c o in cid en ta l. N o p art o f t h is p ub lic a tio n m ay b e
r e p ro duced , s to re d i n a r e tr ie va l s y ste m , u se d i n a s p re a dsh eet, o r t r a nsm itte d i n a ny f o rm o r b y a ny
m ea ns-e le ctr o nic , m ech anic a l, p hoto co pyin g , r e co rd in g o r o th erw is e w ith out t h e p erm is sio n o f t h e
U niv ersity o f M in neso ta .
2 008 U niv ersity o f M in neso ta B oard o f R eg en ts . T he U niv e rsity o f M in neso ta i s a n e q ual- o pportu nity
e m plo yer a nd e d uca to r. T his d o cu m en t i s a va ila ble i n a lte rn a te f o rm ats . F or i n fo rm atio n, c o nta ct B arb a ra
B la lo ck 6 12 -6 2 6-7 3 79
S en tin el E ven t
D ay O ne
J a n e N ag el i s a n 1 8-y ear- o ld w om an w ho p re se n te d t o t h e e m erg en cy d ep artm en t ( E D ) a t
5 p .m . c o m pla in in g t h at s h e w as “ n ot f e elin g w ell.” S he t o ld t h e a d m ittin g s ta ff s h e h ad
n asa l c o n gestio n, s tu ffin ess, s o re t h ro at a n d a c o u gh f o r t h e l a st c o uple w ee k s. S he a ls o
h ad a ch y j o in ts a n d c h est d is c o m fo rt o n t h e r ig h t s id e. I n f a ct, h er c o u gh l e d h er t o q u it
s m okin g f o r t w o w eek s. S he h ad n ot b een d rin kin g o r e atin g m uch d urin g t h e l a st f e w
d ay s, a n d s h e s a id h er u rin e w as d ark er t h an u su al.
M ary W ood, R N o bta in ed h er v ita l s ig n s i n t h e E D . H er t e m pera tu re w as 9 5.4 °F a n d
p uls e w as 8 3 b eats p er m in ute . H er b lo od p re ssu re w as 1 02/5 9 m mHg, r e sp ir a tio ns w ere
1 6 b re ath s p er m in ute a n d o x yg en s a tu ra tio n w as 1 00 p erc en t o n r o om a ir .
J a m es H all, M .D ., s a w h er i n t h e e m erg en cy r o o m . H e o bta in ed t h e a b ov e h is to ry a n d
l e arn ed s h e h ad s to pped h er P la q uen il a b out t w o m onth s a g o ( th e p h ysic ia n s c o m ple te t h e
m ed ic in e r e co ncilia tio n p ro cess i n t h e E m erg en cy D ep artm en t) . J a n e t o ld t h e d octo r t h at
i t h ad n ot h elp ed c o ntr o l h er l u pus, s o s h e h ad d ecid ed t o q uit t a k in g i t w ith out c o nsu ltin g
h er p h ysic ia n .
J a n e’s S L E ( lu pus) w as d ia g n ose d t w o y ea rs a g o w hen s h e p re se n te d w ith a n a rr a y o f
s y m pto m s a n d f in din gs t h at i n clu ded j o in t p ain , b lo od i n h er u rin e, c h est d is c o m fo rt a n d a
p ositiv e d ouble -s tr a n ded D NA a n d A NA. A r h eu m ato lo gis t s a w h er i n itia lly a n d h as
f o llo w ed h er c are i n te rm itte n tl y s in ce t h e i n itia l d ia g n osis . H ow ev er J a n e o fte n i s u nab le
t o g o t o h er a p poin tm en ts b ecau se o f h er l a ck o f t r a n sp orta tio n. B ecau se t h e h osp ita l a n d
c lin ic h av e r e cen tl y c o nv erte d t o a n e le ctr o nic h ea lth r e co rd ( E H R), o nly t h e l a st n in e
m onth s’ w orth o f a p poin tm en ts a re a v aila b le ( th e r e st a re i n t h e p ap er c lin ic c h art, w hic h
i s l o cate d i n t h e c lin ic ).
J a n e’s p h ysic al e x am in atio n w as e sse n tia ll y n o rm al, a lth ough J a m es H all, M .D ., t h ou gh t
s h e a p pea re d m ild ly d eh yd ra te d . H e o rd ere d s o m e i n tr a v en ous n orm al s a lin e. H er c h est
x -ra y w as r e ad b y J a m es H all, M .D ., a s c le ar a n d w as u nch an ged c o m pare d t o o ne d o ne
a t t h e s a m e h osp ita l j u st t h re e w eek s a g o . T his x -ra y h ad b een d one i n t h e E D w hen J a n e
h ad p re se n te d f o r c h est p ain , w hic h w as u ltim ate ly a ttr ib ute d t o h er l u pus. S he h ad b een
a d vis e d t o s e e h er r h eu m ato lo gis t b ut h ad n ot m ad e t h e a p poin tm en t. T o a ssis t w ith
d ia g n osin g h er c h ie f c o m pla in ts , m ultip le b lo od a n d u rin e l a b ora to ry t e sts w ere o rd ere d
d urin g t h is v is it t o t h e E D . ____________________________________________________________________ ____
T he U nfo rtu n ate A dm is sio n Pag e 3 o f 8
T his c a se s tu dy w as p re p are d f o r t h e C LA RIO N I n te rp ro fe ssio nal C ase C om petitio n. I t w as d evelo ped a s
t h e b asis f o r d is c u ssio n i n t h e C ase C om petitio n. I n fo rm atio n i n t h is c a se i s f a bric a te d /fic titio us. A ny
r e se m bla nce t o a ny h ea lth ca re p ro vid er i s p ure ly c o in cid en ta l. N o p art o f t h is p ub lic a tio n m ay b e
r e p ro duced , s to re d i n a r e tr ie va l s y ste m , u se d i n a s p re a dsh eet, o r t r a nsm itte d i n a ny f o rm o r b y a ny
m ea ns-e le ctr o nic , m ech anic a l, p hoto co pyin g , r e co rd in g o r o th erw is e w ith out t h e p erm is sio n o f t h e
U niv ersity o f M in neso ta .
2 008 U niv ersity o f M in neso ta B oard o f R eg en ts . T he U niv e rsity o f M in neso ta i s a n e q ual- o pportu nity
e m plo yer a nd e d uca to r. T his d o cu m en t i s a va ila ble i n a lte rn a te f o rm ats . F or i n fo rm atio n, c o nta ct B arb a ra
B la lo ck 6 12 -6 2 6-7 3 79
Ja m es H all, M .D ., p la n ned t o d is c h arg e M s. N ag el a fte r t h e I V f lu id s w ere a d m in is te re d ,
b ut h e d ecid ed t o a d m it h er t o t h e h osp ita l w hen s h e t o ld h im t h at h er p ain w as v ery
s im ila r t o t h e p ain t h at l e ad t o h er l u pus d ia g n osis t w o y ears a g o . H e a g re ed w ith J a n e’s
s u ggestio n t h at s h e m ig h t b e h av in g a f la re o f h er d is e ase b ecau se s h e s to pped t a k in g h er
m ed ic atio n. J a m es H all, M .D ., t o ld t h e a tte n din g g en era l m ed ic in e p h ysic ia n h e
r e co m men ded s h e b e a d m itte d .
U pon a d m is sio n t o t h e G en era l M ed ic in e U nit, G ra n t T hom pso n, M .D ., t h e i n te rn o n c all,
o bta in ed s o m e a d ditio nal h is to ry . J a n e w as a ls o d ia g n ose d a s b ip ola r d is o rd er a n d h ad
b een a d m itte d n in e m onth s a g o t o a p sy ch ia tr ic u n it i n a h osp ita l i n t h e s a m e s y ste m f o r a
s u ic id e a tte m pt. J a n e l iv es i n a s o ber h ouse a fte r c o m ple te d t r e atm en t f o r d ru g a b use . S he
h as s o m e b io lo gic al f a m ily b ut w as p la ced i n t h e f o ste r-c a re s y ste m f o r s ix y ears a fte r
b ein g r e m oved f ro m h er m oth er’s h ouse b ecau se o f h er m oth er’s d ru g a d dic tio n. H er
o ld er s is te r a ls o s u ff e rs f r o m d ru g a n d a lc o hol a d dic tio n. J a n e d en ie d u sin g a n y s tr e e t
d ru gs o r a lc o hol.
T he c o m ple te p h ysic al e x am in atio n d one b y G ra n t T hom pso n, M .D ., w as n orm al. H er
w hite b lo od c o unt, h em oglo bin a n d e le ctr o ly te s w ere a ll w ith in n orm al r a n ges. G ra n t
o rd ere d m ultip le o th er l a b ora to ry t e sts , a u rin e t o x ic o lo g y s c re en a n d a p re g nan cy t e st.
H e a ls o o rd ere d a p sy ch ia tr y c o nsu lt b ec au se J a n e h ad t o ld h im t h at s h e h ad n ot b een
s e ein g a t h era p is t o r p sy ch ia tr is t n or t a k in g a n y m ed ic atio ns f o r h er b ip ola r d is o rd er.
A bout 9 p .m ., J a n e’s l a b ora to ry w ork w as c o m ple te d . H er e ry th ro cy te s e d im en ta tio n r a te
w as 7 3 m m/h ( n orm al 0 -2 0 m m/h ). T he n asa l s w ab f o r i n flu en za, r a p id s tr e p to co ccal
s c re en a n d u rin e p re g n an cy t e st w ere n eg ativ e.
G ra n t T hom pso n, M .D ., b rie fly d is c u sse d t h e c ase o ver t h e p hone w ith t h e a tte n din g
p h ysic ia n M arc C ash , M .D . T hey a g re ed t h at t h e l i k ely d ia g n osis w as a f la re o f h er l u pus
w ith a c o m plic atin g s y ste m ic v ir a l o r u rin ary t r a ck i n fe ctio n. T hey d ecid ed t o r e sta rt h er
P la q uen il, s ta rt p re d nis o ne a t 2 0m g p er d ay a n d c o nsu lt r h eu m ato lo g y t h e n ex t d ay . G ra n t
w ro te t h is o rd er o n h is w ay h om e a t 9 :3 0 p .m .
A t 1 0 p .m . t h e p harm ac y r e ceiv ed t h e o rd ers , a n d J a m es M ille r, P harm .D ., r e v ie w ed t h e
o rd ers . H e w ro te a n ote t o a sk w hen J a n e h ad h er l a st e y e e x am . B ecau se h e w an te d t o
f o llo w -u p o n t h e p atie n t’ s h is to ry , J a m es d ecid ed n ot t o f ill t h e P la q uen il t h at n ig h t, s in ce
i t w as w ritte n a s “ q day .” H e s e n t u p t h e p re d nis o ne d ose .
____________________________________________________________________ ____
T he U nfo rtu n ate A dm is sio n Pag e 4 o f 8
T his c a se s tu dy w as p re p are d f o r t h e C LA RIO N I n te rp ro fe ssio nal C ase C om petitio n. I t w as d evelo ped a s
t h e b asis f o r d is c u ssio n i n t h e C ase C om petitio n. I n fo rm atio n i n t h is c a se i s f a bric a te d /fic titio us. A ny
r e se m bla nce t o a ny h ea lth ca re p ro vid er i s p ure ly c o in cid en ta l. N o p art o f t h is p ub lic a tio n m ay b e
r e p ro duced , s to re d i n a r e tr ie va l s y ste m , u se d i n a s p re a dsh eet, o r t r a nsm itte d i n a ny f o rm o r b y a ny
m ea ns-e le ctr o nic , m ech anic a l, p hoto co pyin g , r e co rd in g o r o th erw is e w ith out t h e p erm is sio n o f t h e
U niv ersity o f M in neso ta .
2 008 U niv ersity o f M in neso ta B oard o f R eg en ts . T he U niv e rsity o f M in neso ta i s a n e q ual- o pportu nity
e m plo yer a nd e d uca to r. T his d o cu m en t i s a va ila ble i n a lte rn a te f o rm ats . F or i n fo rm atio n, c o nta ct B arb a ra
B la lo ck 6 12 -6 2 6-7 3 79
D ay T w o
J a n e h ad a r e stle ss n ig h t a n d d id n ot s le ep w ell. T he n ig h t n urs e f o und a s le ep er c h air f o r
h er b o yfrie n d, w ho h ad s p en t t h e n ig h t i n h er r o o m .
W hen G ra n t T hom pso n, M .D ., a rriv ed a t 7 :3 0 a .m . t h e n ex t m orn in g, h e r e v ie w ed h er
v ita l s ig n s a n d t h e m orn in g l a b ora to ry w ork p rio r t o s e ein g h er. J a n e h ad r e ceiv ed a t o ta l
o f 1 .5 l ite rs o f n orm al s a lin e s in ce a d m is sio n.
H er u rin aly sis s h ow ed 1 0 m g/d l k eto nes, 3 s q uam ous e p ith elia l c ells /h ig h p ow er f ie ld ,
t r a ce l e u ko cy te e ste ra se , 1 1 W BC / h ig h p ow er f ie ld a n d m uco us. C onsis te n t w ith a l u pus
f la re , J a n e’s c o m ple m en t c o ncen tr a tio ns w ere a C 3 o f 5 1m g/d l ( 9 0-2 00 ), a C 4 o f 4 m g/d l
( 1 5-5 0) a n d a C H 50 o f 2 2m g/d l ( 6 0-1 44). T he s p utu m g ra m s ta in s h ow ed m ix ed g ra m -
p ositiv e a n d g ra m -n eg ativ e o rg an is m s w ith l e ss t h an 10 s q uam ous e p ith elia l c ells /lo w
p ow er f ie ld . H er b lo od c u ltu re w as n eg ativ e a t l e ss t h an 2 4 h ours . H er u rin e t o x ic o lo g y
s c re en w as p ositiv e f o r a ceta m in ophen , c aff e in e a n d o pia te s. G ra n t T hom pso n c h eck ed
t h e E D n ote a n d d id n ot s e e a n y n ote t h at t h ey h ad g iv en h er o pia te s f o r p ain .
G ra n t T hom pso n, M .D ., s a w J a n e o n p atie n t r o un ds. S he w as l y in g i n h er h osp ita l b ed
w ith h er b o yfrie n d. G ra n t b elie v ed J a n e l o oked b ette r t h an t h e p re v io us d ay . T he
r h eu m ato lo gis t w ho s a w h er l a te r t h at d ay a ls o f e lt t h at s h e h ad a l u pus f la re w ith a
c o nco m ita n t v ir a l i n fe cti o n. G ra n t a n d t h e a tte n din g p h ysic ia n d is c u ss e d J a n e’s c ase .
B oth b elie v ed s h e s h ould b e r e ad y f o r d is c h arg e b y t h e n ex t d ay . T hey a g re ed s h e s h o uld
b e s ta rte d o n l e v oflo x acin f o r a u rin ary t r a ct i n fe c tio n. T hom pso n n ote d t h e n eed f o r t h e
a n tib io tic i n h is d ail y d o cu m en ta tio n.
A bout 1 0 a .m . J o F ors y th , P harm .D ., t h e p harm acis t f o r t h e d ay , c alle d G ra n t T hom pso n,
M .D ., t o a sk a b out J a n e’s l a st e y e e x am . G ra n t d id n’t k now w hen t h e a p poin tm en t w as.
A fte r t a lk in g w ith J o , t h ey d ecid ed t o s ta rt t h e m ed ic atio n b ut w ro te a n o rd er f o r a n
o phth alm olo gis t e x am b efo re J a n e w as d is c h arg ed . G ra n t n ote d t h e o rd er o n t h e s h ee ts
t h at h e c arrie s i n h is p ock et f o r e ach p atie n t t o r e m in d h im se lf t o o rd er a n e x am .
A t 4 p .m ., G ra n t T hom pso n, M .D ., n otic ed t h at n o p sy ch ia tr y n ote w as o n t h e c h art. H e
a sk ed t h e n urs e , J a ck ie B illin gs, R N , i f s o m eo ne f r o m t h e c o nsu lt t e am h ad s e en J a n e.
J a ck ie d id n ot t h in k s o . G ra n t d ouble -c h eck ed t o e n su re t h e o rd er h ad b een r e m oved b y
t h e H ealth U nit C oord in ato r t h e d ay b efo re . H is c h eck s h ow ed t h e o rd er w as r e m oved .
H e w as c erta in h e h ad c alle d t h e p sy ch ia tr y d ep artm en t a n d l e ft a m essa g e r e q uestin g t h e
c o nsu lt. P sy ch ia tr y s ta ff d o n ot g iv e o ut a p ag er n um ber o r n am e o f a p h ysic ia n . I n ste ad , ____________________________________________________________________ ____
T he U nfo rtu n ate A dm is sio n Pag e 5 o f 8
T his c a se s tu dy w as p re p are d f o r t h e C LA RIO N I n te rp ro fe ssio nal C ase C om petitio n. I t w as d evelo ped a s
t h e b asis f o r d is c u ssio n i n t h e C ase C om petitio n. I n fo rm atio n i n t h is c a se i s f a bric a te d /fic titio us. A ny
r e se m bla nce t o a ny h ea lth ca re p ro vid er i s p ure ly c o in cid en ta l. N o p art o f t h is p ub lic a tio n m ay b e
r e p ro duced , s to re d i n a r e tr ie va l s y ste m , u se d i n a s p re a dsh eet, o r t r a nsm itte d i n a ny f o rm o r b y a ny
m ea ns-e le ctr o nic , m ech anic a l, p hoto co pyin g , r e co rd in g o r o th erw is e w ith out t h e p erm is sio n o f t h e
U niv ersity o f M in neso ta .
2 008 U niv ersity o f M in neso ta B oard o f R eg en ts . T he U niv e rsity o f M in neso ta i s a n e q ual- o pportu nity
e m plo yer a nd e d uca to r. T his d o cu m en t i s a va ila ble i n a lte rn a te f o rm ats . F or i n fo rm atio n, c o nta ct B arb a ra
B la lo ck 6 12 -6 2 6-7 3 79
th ey o nly h av e a t e le p ho ne w ith a n a n sw erin g m ach in e. T his i s h ow a ll c o nsu lt r e q uests
m ust b e m ad e.
F ru str a te d b y t h e l a ck o f r e sp onse b y t h e p sy ch ia tr y d ep artm en t, G ra n t T ho m pso n, M .D .,
c alle d t h e h osp ita l o pera to r t o o bta in t h e n am e o f s o m eo ne t o p ag e. H e f in all y m an ag ed
t o r e ach t h e a d m in is tr a tiv e a ssis ta n t o f t h e p sy ch ia tr y d ep artm en t. S he s a id t h e
d ep artm en t d id n’t h av e a r e co rd o f t h e c o nsu lt r e q uest. S he s a id t h ey ’d h ad s o m e
p ro ble m s w ith t h e a n sw erin g m ach in e. S he c o nn ecte d G ra n t w ith o ne o f t h e s ta ff
p sy ch ia tr is ts , w ho r e co m men ded t h at J a n e f o llo w -u p a s a n o utp atie n t s in ce s h e w as n ot
a ctiv ely s u ic id al. H e g av e G ra n t a p ho ne n um ber t o g iv e t o J a n e s o s h e c o uld s c h ed ule a n
a p poin tm en t. A ngry a b o ut t h is l a p se i n c are , G ra n t l e ft a fte r s p en din g 4 5 m in ute s o n t h is
i s su e. I n h is h aste t o l e av e, h e f o rg o t t o w rite t h e o rd er f o r t h e l e v oflo x acin .
I t w as F rid ay , a n d T ra c ey W ells , M .D ., w as c o v erin g f o r t h e a tte n din g p h ysic ia n M arc
C ash , M .D ., t h at w eek en d. M arc d is c u sse d t h e p atie n ts o ver t h e p hone w it h t h e T ra c e y
a n d i n dic ate d h e t h ou gh t J a n e w as i m pro vin g a n d s h e s h ould b e d is c h arg ed t o m orro w .
A t 6 p .m ., B eth M ir ro w , L PN , n otic ed t h at J a n e’s v ita l s ig n s i n dic ate d t h at s h e h ad a
f e v er o f 1 01.3 °F a n d a p u ls e o f 1 18 b eats p er m in ute . B eth c alle d t h e o n-c all i n te rn w ho
o rd ere d a n oth er s e t o f b lo od c u ltu re s a n d r e co m m en ded t h at a ceta m in ophen b e g iv en f o r
t h e f e v er. B eth e n su re d t h e o rd ers w ere c o m ple te , a n d J a n e’s t e m pera tu re d ecre ase d i n
o ne h our. T he o n -c all i n te rn d id n ot h av e a c h an ce t o w rite d ow n t h is i n fo rm atio n a n d h er
d ecis io ns t o o rd er t h e c u ltu re a n d m ed ic atio n a n d f o rg o t t o p ass i t a lo n g t o G ra n t
T hom pso n, M .D ., t h e n ex t m orn in g
D ay T hree
J a n e f e lt w ors e o n S atu rd ay m orn in g. A fte r h er s h if t w as f in is h ed , K im F ra n klin , R N ,
e n te re d J a n e’s m orn in g v ita l s ig n s a t 7 :1 9 a .m ., w hic h w ere a t e m pera tu re o f 1 01.3 °F ,
p uls e o f 1 40 b eats p er m in ute , b lo od p re ssu re o f 1 05/4 6, r e sp ir a tio ns o f 3 0 b re ath s p er
m in ute , a n d o x yg en s a tu ra tio n o f 9 3 p erc en t o n r o om a ir . S he m ad e a n ote i n t h e
e le ctr o nic v ita ls s e ctio n t h at “ re p o rt w as g iv en t o A M s h if t f o r i n te rv en tio n .”
G ra n t T hom pso n, M .D ., c am e i n t o w ork o n S atu rd ay a t 7 a .m . H e w as h op in g t o g et
f in is h ed a n d l e av e a l ittle e arly t o e n jo y t h e g o od w eath er. J a n e w as t h e f ir s t p ers o n h e
s a w . H er b o yfrie n d w as o nce a g ain i n t h e b ed w it h h er. J a n e w as s le ep y b u t o th erw is e h er
e x am w as n ote d t o b e n orm al. I t i s n ot c le ar w heth er o r n ot h e c h eck ed h er m orn in g v ita l ____________________________________________________________________ ____
T he U nfo rtu n ate A dm is sio n Pag e 6 o f 8
T his c a se s tu dy w as p re p are d f o r t h e C LA RIO N I n te rp ro fe ssio nal C ase C om petitio n. I t w as d evelo ped a s
t h e b asis f o r d is c u ssio n i n t h e C ase C om petitio n. I n fo rm atio n i n t h is c a se i s f a bric a te d /fic titio us. A ny
r e se m bla nce t o a ny h ea lth ca re p ro vid er i s p ure ly c o in cid en ta l. N o p art o f t h is p ub lic a tio n m ay b e
r e p ro duced , s to re d i n a r e tr ie va l s y ste m , u se d i n a s p re a dsh eet, o r t r a nsm itte d i n a ny f o rm o r b y a ny
m ea ns-e le ctr o nic , m ech anic a l, p hoto co pyin g , r e co rd in g o r o th erw is e w ith out t h e p erm is sio n o f t h e
U niv ersity o f M in neso ta .
2 008 U niv ersity o f M in neso ta B oard o f R eg en ts . T he U niv e rsity o f M in neso ta i s a n e q ual- o pportu nity
e m plo yer a nd e d uca to r. T his d o cu m en t i s a va ila ble i n a lte rn a te f o rm ats . F or i n fo rm atio n, c o nta ct B arb a ra
B la lo ck 6 12 -6 2 6-7 3 79
sig n s o r t h ose f ro m t h e e v en in g b efo re . A lth ough t h at i n fo rm atio n i s o n t h e c o m pute r,
t h ere i s n o w ay t o d ete rm in e w ho a c cesse d t h e i n fo rm atio n.
L en C am ero n, L PN , l e arn ed a b out J a n e’s t e m pera tu re f ro m K im F ra n klin , R N . T his w as
h is t h ir d s h if t o n t h e M ed ic al/S urg ic al w ard . H e h ad j u st b een h ir e d a fte r w ork in g f o r
t h re e y ears a t a l o cal t r a n sitio nal c are f a cilit y . P er h er s ta n din g o rd ers , L en g av e J a n e
s o m e o f t h e “ as n eed ed ” a ceta m in ophen a s w ell a s a n o x yco done f o r t h e r ig ht- s id ed c h est
p ain a b out w hic h J a n e h ad s ta rte d c o m pla in in g. H e r e ch eck ed h er v ita l s ig n s a t 9 :1 1 a .m .
H er t e m pera tu re d ec re ase d t o 1 00.4 °F , a n d h er p uls e w as 1 23 b eats p er m in ute . H e s a w
t h at s h e h ad b lo od c u ltu re s d ra w n t h e p re v io us e v en in g s o h e d id n ot c all t h e i n te rn a n d
d is c u ss J a n e’s s ta tu s.
G ra n t T hom pso n, M .D ., a n d t h e c o verin g a tte n din g p h ysic ia n , T ra c e y W ells , M .D .,
d is c u sse d J a n e’s c ase a t 9 a .m . G ra n t m is ta k en ly r e p orte d y este rd ay ’s v ita l s ig n s t o
T ra c e y . D urin g t h eir d is c u ssio n a b out J a n e, G ra n t r e aliz ed t h at h e h ad f o rg o tte n t o w rite
t h e a n tib io tic o rd er. H e w as a fra id t o t e ll T ra c e y b ecau se s h e h ad a r e p uta tio n f o r b ein g
v ery h ard o n i n te rn s. T hey d ecid ed J a n e c o uld b e d is c h arg ed , a n d G ra n t w ro te t h e o rd ers .
L en C am ero n, L PN t o ok t h e d is c h arg e f o rm s a n d w en t o ver t h em w ith J a n e. S he s a id t h at
s h e f e lt p oorly , w as h av in g s o m e t r o uble b re ath in g a n d r e all y d id n ot w an t t o g o . L en
c alle d G ra n t T hom pso n, M .D ., a n d t o ld h im t h at “ th e p atie n t d oes n ot f e el r e ad y t o g o
h om e” b ut d id n ot c o nvey a n y o th er i n fo rm atio n t o G ra n t o r g iv e h is o pin io n. G ra n t t o ld
L en t h at J a n e h ad a lr e ad y s ta y ed a n e x tr a d ay b eca u se o f t h e m ix -u p w ith t h e p sy ch ia tr y
c o nsu lt. L en w as u nsu re w hen t o c all a n a tte n din g p h ysic ia n a n d d id n’t w an t t o g et t h e
i n te rn i n t r o uble . H e t o ld J a n e t h at t h e m ed ic al s ta ff f e lt t h at s h e c o uld g o h o m e. S he w as
d is c h arg ed a t 1 0 a .m . a n d t h en t o ok t h e b us h om e.
A t 1 1 a .m ., G ra n t T hom pso n, M .D ., f in is h ed r o un din g, w ritin g o rd ers f o r h is p atie n ts a n d
w en t h om e. G ra n t d ouble -c h eck ed J a n e’s i n itia l b lo od c u ltu re s d ra w n i n t h e E D . T ho se
c u ltu re s r e m ain ed n eg ati v e. H e d id n ot s e e t h at b lo od c u ltu re s h ad b een d ra w n t h e
p re v io us e v en in g. L ab o ra to ry t e sts t h at d o n ot h av e r e p orte d r e su lts ( s u ch a s t h e c u lt u re s
f ro m t h e p re v io us n ig h t) d o n ot s h ow u p i n t h e l a b ora to ry s e ctio n o n t h e n ew E H R u n le ss
y o u c lic k “ sh ow p en din g” n ex t t o t h e t e sts y o u w an t t o s e e. G ra n t i s a n ew u se r o f t h e
E H R a n d d id n’t k now w hic h t a b t o c lic k . S in ce i t w as S atu rd ay , G ra n t c o u ld n ot m ak e
t h e o phth alm olo g y a p poin tm en t. C lin ic s c h ed ulin g i s o pen f ro m M onday t h ro ugh F rid ay .
I n ste ad , h e w ro te t h e p ho ne n um ber f o r t h em o n J a n e’s d is c h arg e o rd ers .
____________________________________________________________________ ____
T he U nfo rtu n ate A dm is sio n Pag e 7 o f 8
T his c a se s tu dy w as p re p are d f o r t h e C LA RIO N I n te rp ro fe ssio nal C ase C om petitio n. I t w as d evelo ped a s
t h e b asis f o r d is c u ssio n i n t h e C ase C om petitio n. I n fo rm atio n i n t h is c a se i s f a bric a te d /fic titio us. A ny
r e se m bla nce t o a ny h ea lth ca re p ro vid er i s p ure ly c o in cid en ta l. N o p art o f t h is p ub lic a tio n m ay b e
r e p ro duced , s to re d i n a r e tr ie va l s y ste m , u se d i n a s p re a dsh eet, o r t r a nsm itte d i n a ny f o rm o r b y a ny
m ea ns-e le ctr o nic , m ech anic a l, p hoto co pyin g , r e co rd in g o r o th erw is e w ith out t h e p erm is sio n o f t h e
U niv ersity o f M in neso ta .
2 008 U niv ersity o f M in neso ta B oard o f R eg en ts . T he U niv e rsity o f M in neso ta i s a n e q ual- o pportu nity
e m plo yer a nd e d uca to r. T his d o cu m en t i s a va ila ble i n a lte rn a te f o rm ats . F or i n fo rm atio n, c o nta ct B arb a ra
B la lo ck 6 12 -6 2 6-7 3 79
A t 1 2:1 5 p .m ., t h e m ic ro bio lo g y l a b ora to ry t e ch nic ia n p ag ed t h e o n-c all i n te rn , J e ff
S pla in e, M .D . T he b lo od c u ltu re s d ra w n t h e p re v io us e v en in g w ere b oth p ositiv e f o r
g ra m -n eg ativ e b acte ria , i n dic atin g J a n e h ad a b acte re m ia a n d w as p ote n tia lly s e p sis . T he
i n te rn w en t t o t h e m ed ic a l u nit a n d q uic k ly l o oked t h ro ugh J a n e’s r e co rd s t o d ete rm in e
h er s ta tu s a t d is c h arg e. C oncern ed f o r h er, a t 1 p .m . h e c alle d J a n e a t t h e S ober H ouse
a n d a sk ed h er h ow s h e w as f e elin g. S he t o ld h im t h at s h e w as e x hau ste d , c o ugh in g a n d
f e lt w arm a n d s w eaty . J e ff a d vis e d h er t o i m med ia te ly c o m e b ack t o t h e h osp ita l.
J a n e t o ld h im t h at s h e h ad j u st g o tte n h om e a n d w as e x hau ste d . S he h ad n o c ar o r r id e
a n d d id n ot h av e e n ou gh e n erg y t o w alk b ack t o t h e b us s to p. J e ff S pla in e, M .D ., p la c ed
h er o n h old a n d t r ie d t o f in d o ut i f t h e h osp ita l c o uld p ay f o r a c ab . T he c h arg e n urs e a t
t h e f ro nt d esk s a id t h ere w as n ot a m ech an is m t o g et t h at d on e. J e ff a p olo giz ed t o J a n e
a n d s a id h e d id n’t t h in k a c ab w as p ossib le . H e e m phasiz ed t h e n eed f o r h er t o c o m e r ig h t
b ack a n d g o d ir e ctl y t o t h e M ed ic in e C are U nit.
J a n e f in all y a rriv ed a t t h e h osp ita l b y b us a t 7 :1 5 p .m . a n d w as i m med ia te ly a d m itte d t o
t h e M ed ic in e C are U nit. S he w as c le a rly e x hau ste d , f lu sh ed a n d d ia p hore tic . A t 7 :2 3
p .m ., h er v ita l s ig n s w ere a t e m pera tu re o f 1 04.7 °F , p uls e o f 1 49 b eats p er m in ute , b lo od
p re ssu re o f 1 00/3 8 m mHg, r e sp ir a tio ns o f 4 0 b re a th s p er m in ute , a n d o x yg en s a tu ra ti o n
o f 9 2 p erc en t. J e ff S pla in e, M .D ., e x am in ed h er w ith in a f e w m in ute s o f h er a rriv al a n d
q uic k ly c o n clu ded t h at s h e w as i n s e p tic s h ock . H e a n d t h e n urs in g s ta ff i m med ia te ly
t r a n sfe rre d h er t o t h e M ed ic al I n te n siv e C are U nit a n d b eg an m ultip le i n tr a v en ous
a n tib io tic s i n clu din g c eftr ia x one, v an co m ycin a n d l e v oflo x acin .
J a n e h ad n ot t a k en a n y o f t h e m ed ic atio ns, i n clu din g t h e l e v o flo x acin , g iv en u pon
d is c h arg e b ecau se s h e w as w orn o ut a n d s li g h tl y n au se ate d .
J a n e r a p id ly d eco m pen sa te d d urin g t h e n ex t t w o h ours . S he p ro gre sse d i n to a cu te
r e sp ir a to ry d is tr e ss, h ad t o b e i n tu bate d a n d p la ced o n a v en tila to r. H er c h est x -ra y
r e v eale d n ew a ir s p ac e o p acitie s i n b oth l u ngs c o nsis te n t w ith b ila te ra l p neu m onia o r
a cu te r e sp ir a to ry d is tr e ss s y n dro m e. H er b lo od p re ssu re d ro pped a n d m ultip le
v aso pre sso rs w ere s ta rte d t o m ain ta in h er b lo od p re ssu re .
D esp ite h ero ic m easu re s, h er b lo od p re ssu re c o uld n ot b e s ta b iliz ed . J a n e d ie d a t 2 :1 2
p .m . t h e n ex t d ay .
____________________________________________________________________ ____
T he U nfo rtu n ate A dm is sio n Pag e 8 o f 8
T his c a se s tu dy w as p re p are d f o r t h e C LA RIO N I n te rp ro fe ssio nal C ase C om petitio n. I t w as d evelo ped a s
t h e b asis f o r d is c u ssio n i n t h e C ase C om petitio n. I n fo rm atio n i n t h is c a se i s f a bric a te d /fic titio us. A ny
r e se m bla nce t o a ny h ea lth ca re p ro vid er i s p ure ly c o in cid en ta l. N o p art o f t h is p ub lic a tio n m ay b e
r e p ro duced , s to re d i n a r e tr ie va l s y ste m , u se d i n a s p re a dsh eet, o r t r a nsm itte d i n a ny f o rm o r b y a ny
m ea ns-e le ctr o nic , m ech anic a l, p hoto co pyin g , r e co rd in g o r o th erw is e w ith out t h e p erm is sio n o f t h e
U niv ersity o f M in neso ta .
2 008 U niv ersity o f M in neso ta B oard o f R eg en ts . T he U niv e rsity o f M in neso ta i s a n e q ual- o pportu nity
e m plo yer a nd e d uca to r. T his d o cu m en t i s a va ila ble i n a lte rn a te f o rm ats . F or i n fo rm atio n, c o nta ct B arb a ra
B la lo ck 6 12 -6 2 6-7 3 79
T he b lo od c u ltu re s f ro m t h e e v en in g o f t h e s e co nd d ay o f h er h osp ita liz atio n g re w
H em ophilu s i n flu en zae. H er a u to psy r e v eale d b ila te ra l g ra m -n eg ativ e p neu m onia w ith
b acte re m ia a n d m ulti- o rg an f a ilu re , l ik ely f ro m s e p tic s h ock .
