Read “The Case of Mr. Baum (PDF).”
Create a fishbone diagram of this case for the Quality Improvement Team. You may download and use the Fishbone Template (Word). (10 points)
Identify process improvements that could reduce the likelihood that these errors/failures will recur in the future. (10 points)
The Case of Mr. Baum
Quality Improvement Case Study—Fishbone Analysis)
Mr. Henry Baum is a 72-year-old man with a long-standing history of a seizure
disorder. He also has hypertension (high blood pressure) and chronic obstructive
pulmonary disease (COPD). He is no stranger to the hospital because of his health
issues. At home, he takes a number of medications, including three for his COPD and
levetiracetam and lamotrigine to help control his seizures.
Mr. Baum came to the emergency department (ED) last week because he was
wheezing and having trouble breathing. The physician in the ED conducted a physical
examination that yielded signs of an acute COPD exacerbation.
The physician in the ED ordered a chest x-ray, which did not show any signs of
pneumonia. He admitted Mr. Baum to the hospital for treatment of acute COPD
exacerbation, resulting from a relatively mild respiratory tract infection. Before leaving
the ED, Mr. Baum also underwent routine blood work, which showed an elevation in his
creatinine, a sign that his kidneys were being forced to work harder due to his infection.
On the medical floor, the healthcare care team treated Mr. Baum with oral
steroids and inhaled bronchodilators, which resulted in a gradual improvement in his
respiratory symptoms. Nurses also gave him IV fluids for the issue with his kidneys,
which slowly resolved. Mr. Baum was steadily improving, so it seemed this visit to the
hospital would be one of his shorter ones.
But on his third morning in the hospital, Mr. Baum complained to the nurse about
acute pain in his left leg. This symptom, potentially indicating deep vein thrombosis
(DVT), prompted the healthcare team to order an ultrasound of Mr. Baum’s lower
The APN on the healthcare team then checked Mr. Baum’s medication orders
and was surprised to see that the admitting doctor had not ordered prophylaxis for DVT
(i.e., blood thinners, such as heparin or enoxaparin). Patients admitted to the hospital
typically receive this treatment to prevent blood clots from forming while they lie in their
hospital beds. Further, nothing about Mr. Baum’s medical record suggested he shouldn’t
have received this treatment as an important precautionary measure.
The ultrasound, unfortunately, confirmed the presence of a blood clot in Mr.
Baum’s left calf. Due to his impaired kidney function, treatment for the blood clot
required him to remain in the hospital on IV medication. Mr. Baum’s stay was going to
be longer than expected.
At 10 PM on his eighth day in the hospital, a member of the environmental
services (also known as housekeeping) staff found Mr. Baum on the floor of his room.
She immediately alerted the nurses on the unit. The nurses noted seizure activity and
called the on-call APN to Mr. Baum’s bedside. Mr. Baum received intravenous
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medication that stopped his seizure. Because no one witnessed his fall and seizure, Mr.
Baum underwent an emergent CT scan of his head to check for any sign of bleeding.
After his mental status improved he complained of pain in his left shoulder and
elbow, but x-rays of these joints showed no evidence of a traumatic fracture from his fall.
After ensuring that Mr. Baum was stable, the APN reviewed the chart and the medication
history to try to determine the cause of Mr. Baum’s sudden seizure.
It was found that one of his seizure medications, levetiracetam, had not been
given earlier in the day when it should have been. There was a notation in the
medication administration record from the first shift nurse indicating that the ordered
dose was not available in the automatic medication dispensing system on the floor
earlier in the day.
Further discussions the following day with the healthcare team revealed that the
nurse didn’t notify the physician or the pharmacy that the essential medication was not
administered. The medication system didn’t include an automatic alert, either.
Fortunately, the on-call APN restarted Mr. Baum on his medication, and he
suffered no apparent permanent harm. Mr. Baum was discharged after 10 days in the
hospital. Most hospitalizations for COPD are far shorter. In fact, many last only a couple