Adverse Events

I chose to attend the Telluride Experience because intern year of my residency program, I was involved in a negative patient safety event. A patient being taken care of by my team was discharged from the hospital with the wrong type of antibiotic medication.
The patient had a community acquired pneumonia. He was responding to our initial antibiotic regimen and we were prepping for discharge. Though improving clinically, blood cultures came back positive. We waited for results and acted when we saw that the cultures speciated. We anticipated a quick discharge, but our patient kept barely failing discharge vitals parameters and we had to keep delaying sending him home. With pressure to keep our patient census low, the plan was to discharge him as soon as he meet safe discharge criteria.
We discharged him approximately a day later with medication for his specific infection. In our haste to discharge, we did not appreciate that the antibiotic sensitivities, that resulted a few hours before sending him home, indicated that our treatment was sub-therapeutic.
We received a call several days later from antibiotic stewardship that our discharge medication was inappropriate. We called the patient to find out he was doing much worse. When he returned to the hospital, his skin was grey and he was sent to the ICU with an empyema. He fortunately made a full recovery with the appropriate antibiotic regimen.
I went to check on the patient prior to his second discharge. He was sleeping in bed so I didn’t get a chance to talk to him, but his father was at bedside. His father looked tired from worry. I asked him how his son was doing, “better” he said. He thanked me as I left the room. I hadn’t told him why his son had gotten so sick.
If our team, or I, had checked that one critical measure prior to discharge, the patient would not have been sent home with the wrong regimen. Fortunately, a safety feature in the hospital caught the prescription error and the patient was called back. The hospital’s fail-safe mechanism worked, but I was distraught. I felt horrible that I could have let something like this happen to my patient. Eager to prevent this from happening again, I spoke to my co-workers and supervisors. “It happens” or “file a patient safety report” was the response I heard numerous times. But I did not feel like any meaningful action was going to be made.
An emphasis on patient safety is integral to good patient care because mistakes are not isolated and there must be action to keep other patient’s from being hurt.

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.