Need By Sunday @ Noon (No plagiarism)

CASE 5 Incidental Finding

Janet Lewis was a registered nurse at Hillside Community Hospital. She had been working numerous extra shifts to cover hours from vacant positions. On top of that, she was a single mother of a child with developmental disabilities, which frequently left her exhausted. Janet had no family to assist her, and she was new in town. Her work schedule did not allow time for socializing, so she had not yet established any close friends to help in times of need.

Saturday afternoon, Janet was looking forward to going home after working 72 hours that week; she had just three more hours until she could go to bed. Next thing she knew, two of the second shift nurses called sick, and Janet agreed to cover for one of them. The shift was relatively quiet and uneventful until one of Janet's patients was found unresponsive in his room: a code blue at the end of her shift. Janet normally reacted very well in these situations, but she was barely coherent from lack of sleep.

The patient had developed severe bradycardia. The physician attending the call requested atropine. Janet was having trouble focusing, so she asked the physician to clarify; again, atropine was requested. She grabbed a vial from the crash cart, inadvertently reading the label from the vial next to the one she grabbed: lidocaine. She drew up the ordered amount and handed it off to the doctor. The patient's condition worsened. The physician demanded more atropine. Janet was still holding the lidocaine vial and proceeded to dispense the ordered amount. Janet replaced the vial on the crash cart, when the physician ordered additional atropine. She grabbed the vial labeled as atropine and dispensed to the physician. It was at this point that Janet realized she possibly had the wrong medication previously. However, in the hectic moment of the code, she hesitated to inform the physician. After additional resuscitative measures were attempted, the code was called, and the patient was pronounced expired.

The physician spoke with the family immediately after the code, and then they went into the room to view the expired patient. Janet approached the physician when he returned to the nurses' station to complete his documentation. She explained that she possibly gave him the incorrect medication. An incident report was completed, and in the rush, it was filed on the chart instead of being sent to Risk Management. What Janet and the physician did not know was that a member of the patient's family, who was leaving, overheard the conversation but did not address it with Janet or the physician.

Carla was new to the health information management field and was working in her first “real” job at Hillside Community Hospital as an Assembly and Analysis Clerk. She had been in her position for six months and was competent in her work. She occasionally encountered unfamiliar documents and generally asked questions when she found forms that could not determine where to file. Carla worked second shift on Sunday night when she got to the chart with Janet's incident report. She was the only person covering the office on Sunday evenings. When Carla stumbled on the incident report and did not have anybody to ask about it, she simply filed it behind the miscellaneous tab because her trainer failed to mention anything about sending incident reports to Risk Management.

The following week, the patient's family contacted an attorney and presented the hospital with a malpractice lawsuit. A subpoena was sent for copies of the record. The Release of Information Specialist had an unexpected family medical emergency, so others in the department were covering the position. Carla had volunteered to work extra hours and was helping prepare records for release of information. Still unaware that incident reports were not to be part of the medical record, Carla included Janet's incident report in the copies, and they were delivered.

Jose, the Director of Health Information Services, was on vacation during this time. Because Hillside Community Hospital had a small Health Information Services department, there were not any Assistant Director or supervisors. The subpoena required that copies of the records be delivered in person to the Hillside courthouse, so Jose had Carla take them.