Reference no: EM133094515

CASE STUDY - Getting Help When Needed

Claudia Martinelli, a 79 year-old Bostonian, is hospitalized for congestive heart failure. She needs assistance getting in or out of bed. At 11:15 p.m., Claudia needs to use the commode and calls for help using her bedside nurse call button. Unfortunately, the ward clerk does not hear the call because she is away from the nurse station. At 11:30 p.m., Claudia calls the station again, finally reaching the clerk. She explains her need for help, using the remote microphone in her room. Claudia is unable to remember the name of her nurse when asked for it by the clerk. The clerk checks a list for the nurse's name, assuming that it is the nurse assign to Claudia. The clerk places an overhead page for the nurse at 11:35 p.m. Unaware that she has called the wrong nurse, the clerk goes about her work.

At 11:40 p.m., Claudia who is by now quite upset by the delay, calls the clerk again. Realizing her error and with a sense of urgency, the clerk finally pages Claudia's nurse, who arrives at Claudia's room at 11:45 p.m. The nurse is horrified to find Claudia sprawled on the floor and in pain. She had stumbled attempting to reach the commode without assistance.

Claudia subsequently was found to have suffered a fractured hip from the fall, an injury necessitating hip replacement surgery. This was followed by a month-long stay in a rehabilitation facility. Unable to return home, Claudia was transferred to a nursing home. Her family filed a malpractice suit against the hospital.

What role did technology play in Claudia's situation? What role did human error play in her situation?

How might Claudia's fall have been avoided?