Question: Peter W, A 35-year-old Patient With A History Of Multiple Sclerosis And Poor Motor Control, Is Admitted To 2W, A Medical Unit In A Large Urban Hospital. He Is Complaining Of Severe Abdominal Pain And Vomiting. Peter Is Well Known To The Team On The Unit As Having Been Admitted Frequently For Social Problems. Nurse R, Who Is Assigned To Admit The Patient, …
- Peter W, a 35-year-old patient with a history of multiplesclerosis and poor motor control, is admitted to 2W, a medical unitin a large urban hospital. He is complaining of severe abdominalpain and vomiting. Peter is well known to the team on the unit ashaving been admitted frequently for social problems. Nurse R, whois assigned to admit the patient, tells the ED nurse calling withthe report that she “is well aware of the aspects” of Peter W’scase and really does not need too much detail. On admission to theunit, Peter is still complaining of pain, and vomiting a smallamount of “coffee grounds” material. He also has diminished bowelsounds noted on physical exam. Two hours after admission, Peter issent to Radiology for a repeat KUB. Following the x ray and whileawaiting transportation, Peter waits unattended in the corridor.During this time, he vomits and aspirates. A short time later, hehas his x ray and is returned. Following his return, no report isgiven, nor is the team informed of his return. Approximately 15minutes after Peter’s return, Nurse R finds the patient withgasping respirations, and he is markedly cyanotic. Within minutes,Peter is apneic and asystolic. Resuscitation is unsuccessfu
- What went wrong?
- Describe evidence-based practice on appropriate hand-off
- What is a sentinel event?
