"This patient might have died from complications related to her TPN (total parenteral nutrition) infusion," said Dr. Isaac Johnson, Chief Medical Officer at Acme Medical Center (AMC). He was referring to problems that occurred during the treatment of a 16-year old colitis patient, Susan, who had recently been admitted to the hospital on a Friday afternoon with acute abdominal pain. At that time, Susan was taken to the Operating Room (OR) for placement of a Broviac catheter. The line was placed without incident and TPN was begun. Several hours later a nurse noticed a precipitate in the tubing and a tendency for the line to clog. Susan had to be returned to the operating room for removal of the clogged line and the insertion of a new one. She recovered uneventfully and tolerated her further TPN without incident. As required by the hospital, the incident was entered into the Adverse Incident Monitoring System and a root cause analysis performed. Dr. Johnson's review identified weaknesses in the hospital's medication management system, but also suggested that his team's efforts to get every employee engaged in quality improvement were inadequate. He wondered how to hardwire QI into the institution and make it part of the culture.

【書誌情報】

ページ数：9ページ

サイズ：A4

商品番号：HBSP-PH4016

発行日：2014/5/1

登録日：2015/5/11