Reference no: EM133311556
Case Study A: Mr. Jones
Mr. Johnny Jones, an eighty-five-year-old male presented to the emergency department (ED) with a closed-head injury from a fall. He was transferred via ambulance from an assisted living facility. He has one daughter that lives out of state. Mr. Jones was alert and oriented to person, place, and time but still a poor historian. His family was not available during the intake process. However, he did disclose to the nurse he takes medicine for blood pressure and maybe something else. Mr. Jones also communicated to the ED nurse his primary care doctor told him to cut back on salty foods. He told the ED nurse he is not able to get around like he used to, so that is why he lives in an assisted living facility. Mr. Jones was headed to the dining room for lunch when his right knee "gave away" which led to his fall.
When the ED nurse asked Mr. Jones for his daughter's contact information, he was not able to recall his daughter's number. The nurse proceeded to reconcile his medications. Mr. Jones stated he takes two blood pressure pills, a baby aspirin, and a new medicine that the doctor gave him two months ago. He described the new medicine as a "tiny white pill." After becoming frustrated, Mr. Jones told the nurse, "I was just here a few months ago when I had my heart attack, you should have my records." He also inquired, "Aren't my records in the clouds"?
Based on the Mr. Jones's interview, the health team concluded he had a medical history of hypertension, past myocardial infarction, and arthritis.
A medication list based on Mr. Jones's past ED visit:
HCTZ 25 mg by mouth twice daily
Atenolol 50 mg by mouth daily
ASA 81 mg by mouth daily
Aleve by mouth as needed for pain
Nitro SL 0.4 mg as needed for chest pain/ 1 tablet every 5 minutes as needed up to 3 times
Based on assessments performed by the ED doctor and nurse, it was determined Mr. Jones had no neurological deficits. A BMP and CBC were ordered. The results were normal. Mr. Jones was discharged home with instructions to rest, continue his current medications, and follow up with his primary care physician in the morning. His discharge diagnosis was a right-sided hematoma to the scalp region.
Mr. Jones was discharged back to the assisted living facility. During the night, Mr. Jones became unresponsive. He was rushed back to the ED via ambulance in a comatose state. More diagnostics were ordered and completed. The results revealed Mr. Jones had a subdural hematoma, a toxic digoxin level, and an INR of 9.
After finally speaking with the patient's daughter, the health care team learned Mr. Jones is on digoxin 0.5mg by mouth daily for treatment of atrial fibrillation. Also, he had been started on a Coumadin dose of 3 mg by mouth daily. The ED attending physician was very upset. The physician stated, "If this information had been disclosed during his last ED visit on yesterday, I would have ordered an EKG, dig level, PT/INR, and a CT scan without contrast.
The very next day, the ED physician scheduled a meeting with the CEO of the hospital to discuss Mr. Jones's case and how to prevent similar issues from occurring in the future.
Questions for Discussion:
Your group is part of the interdisciplinary team that has been invited to review Mr. Jones's case. The team is to complete a systematic process review to determine the root causes that contributed to Mr. Jones's misdiagnosis. The IP team will make recommendations for the ED so that the ED avoids any reoccurrence of similar issues in the future.
Include all of the following concepts when answering the discussion questions below:
Informatics
EHR
Quality Improvement
Communication
Safety
Interdisciplinary team
What were some of the major contributors to Mr. Jones's misdiagnosis?
What were some of the safety concerns related to Mr. Jones's care?
How pertinent was the omitted information to Mr. Jones's plan of care and his clinical outcomes? How can the omitted information be integrated into an electronic health record (EHR)? Which meaningful use metrics should be considered?
Describe how an IP, approach along with the implementation of the EHR, could have improved Mr. Jones's care resulting in a more favorable outcome and prevent similar issues from occurring.
In regards to the electronic health record, what are 3 recommendations to improve the quality of care provided in the ED?
Case Study B: Mr. Jones
Mr. Johnny Jones, an eighty-five-year-old male presented to the emergency department (ED) with a closed-head injury from a fall. He was transferred via ambulance from an assisted living facility. He has one daughter that lives out of state. Mr. Jones was alert and oriented to person, place, and time but still a poor historian. His family was not available during the intake process. However, he did disclose to the nurse he takes medicine for blood pressure and maybe something else. Mr. Jones communicated to the ED nurse his primary care doctor told him to cut back on salty foods. He also told the ED nurse he is not able to get around like he used to, so that is why he lives in an assisted living facility. Mr. Jones was headed to the dining room for lunch when his right knee "gave away" which led to his fall.
When the ED nurse asked Mr. Jones for his daughter's contact information, he was not able to recall his daughter's number. The nurse proceeded to reconcile his medications. Mr. Jones stated he takes two blood pressure pills, a baby aspirin, and a new medicine that the doctor gave him two months ago. He described the new medicine as a "tiny white pill." After becoming frustrated, Mr. Jones told the nurse, "I was just here a few months ago when I had my heart attack, you should have my records." He also inquired, "Aren't my records in the clouds"?
Based on the Mr. Jones's interview, the health team concluded he had a medical history of hypertension, past myocardial infarction, and arthritis.
A medication list based on Mr. Jones's past ED visit:
HCTZ 25 mg by mouth twice daily
Atenolol 50 mg by mouth daily
ASA 81 mg by mouth daily
Aleve as needed for pain
Nitro SL 0.4 mg as needed for chest pain/ 1 tablet every 5 minutes as needed up to 3 times
During Mr. Jones's interview, he mentioned his previous ED visit after having a heart attack. After reviewing his discharge medications from the prior ED visit, it was determined he was given a new prescription for digoxin 0.5 mg and Coumadin 3 mg by mouth daily for treatment of atrial fibrillation.
After a review of his demographical information from his last ED visit, a power of attorney (POA) for healthcare document was located. The healthcare document included the POA's contact information, Mr. Jones's daughter.
The ED nurse spoke with Mr. Jones's daughter and was able to reconcile his medication list. She obtained the list from her father's local pharmacy.
The ED uses an electronic health record program, Mediscript, which verifies and compiles patients' medications from outpatient/community pharmacies. After the list was compiled for Mr. Jones, here were the final results:
HCTZ 25 mg by mouth twice daily
Atenolol 50 mg by mouth daily
ASA 81 mg by mouth daily
Aleve as needed for pain
Nitro SL 0.4 mg as needed for chest pain/ 1 tablet every 5 minutes as needed up to 3 times
Digoxin 0.5 mg by mouth daily
Coumadin 3 m by mouth daily
Based on the health assessments and interviews, the health team concluded the Mr. Jones had a medical history of hypertension, past myocardial infarction, arthritis, and atrial fib.
The ED physician ordered an EKG, CBC, BMP, dig level, PT/INR, and CT scan of the head without contrast. These diagnostics were ordered based on Mr. Jones's chief complaint, history and the review of the electronic health record. The diagnostics revealed Mr. Jones has a subdural hematoma, his INR is 8.0, and his dig level was toxic.
He was admitted and transferred to the Neurological ICU for observation and care.
Questions for Discussion:
Your group is part of the interdisciplinary team that has been invited to review Mr. Jones's case. The team is to complete a systematic process review to determine Mr. Jones's successful diagnosis and care. You all are asked to make recommendations on which processes to improve the use of the electronic health record (EHR) in the ED to enhance meaningful use and patient outcomes.
Include all of the following concepts when answering the discussion questions below:
Informatics
EHR
Quality Improvement
Communication
Safety
Interdisciplinary team
How could the lack of these systems in place impact client care and outcomes? What were the potential safety issues?
How was the information from the EHR used in patient evaluation and care?
Which meaningful-use-metrics are assumed to have been in place?
What is believed to be the cause(s) of the Mr. Jones's successful diagnoses and plan of care?
In regards to the electronic health record, what are 3 recommendations to maintain or improve the quality of care provided in the ED?