"This patient could 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 difficulties that happened throughout the treatment of a 16-year old colitis patient, Susan, who had lately been admitted to the hospital on a Friday afternoon with acute abdomen pain. The line was established without episode and TPN was started. A precipitate was noticed by several hours later a nurse in a propensity as well as the tubing for the line to clog.
She recovered uneventfully and endured her TPN that was further without incident. The episode was entered into a root cause analysis performed and also the Adverse Incident Monitoring System as required by the hospital. Dr. Johnson's review identified weaknesses in the hospital's drug management system, but also indicated that his team's attempts to get every worker engaged in quality improvement were insufficient. He wondered how to hardwire QI into the association and make it part of the culture.
PUBLICATION DATE: May 01, 2014 PRODUCT #: PH4016-HCB-ENG
This is just an excerpt. This case is about LEADERSHIP & MANAGING PEOPLE
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