The Unfortunate Admission - Institute for Healthcare Improvement

CLARION
An Interprofessional Student Committee of the
Center for Health Interprofessional Programs (CHIP)
UNIVERSITY OF MINNESOTA
The Unfortunate Admission
The details contained in this case were written as a team by
(listed alphabetically)
Karyn Baum, MD, MSEd
Associate Professor of Medicine
Special Assistant to the Dean
School of Medicine
University of Minnesota
Sandra Potthoff, Ph.D.
Associate Professor and Director
Program in Healthcare Administration
School of Public Health
Division of Health Policy and Management
University of Minnesota
Andra Fjone, MN, CPNP
Clinical Associate Professor
School of Nursing
University of Minnesota
William Riley, Ph.D.
Associate Professor
Associate Division Head
School of Public Health
University of Minnesota
Don Uden, Pharm.D.
Professor
Pharmaceutical Care and Health Systems
College of Pharmacy
University of Minnesota
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The Unfortunate Admission Page 1 of 8
This case study was prepared for the CLARION Interprofessional Case Competition. It was developed as
the basis for discussion in the Case Competition. Information in this case is fabricated/fictitious. Any
resemblance to any healthcare provider is purely coincidental. No part of this publication may be
reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in any form or by any
means-electronic, mechanical, photocopying, recording or otherwise without the permission of the
University of Minnesota.
2008 University of Minnesota Board of Regents. The University of Minnesota is an equal-opportunity
employer and educator. This document is available in alternate formats. For information, contact Barbara
Blalock 612-626-7379

Sentinel Event
Day One
Jane Nagel is an 18-year-old woman who presented to the emergency department (ED) at
5 p.m. complaining that she was “not feeling well.” She told the admitting staff she had
nasal congestion, stuffiness, sore throat and a cough for the last couple weeks. She also
had achy joints and chest discomfort on the right side. In fact, her cough led her to quit
smoking for two weeks. She had not been drinking or eating much during the last few
days, and she said her urine was darker than usual.
Mary Wood, RN obtained her vital signs in the ED. Her temperature was 95.4°F and
pulse was 83 beats per minute. Her blood pressure was 102/59 mmHg, respirations were
16 breaths per minute and oxygen saturation was 100 percent on room air.
James Hall, M.D., saw her in the emergency room. He obtained the above history and
learned she had stopped her Plaquenil about two months ago (the physicians complete the
medicine reconciliation process in the Emergency Department). Jane told the doctor that
it had not helped control her lupus, so she had decided to quit taking it without consulting
her physician.
Jane’s SLE (lupus) was diagnosed two years ago when she presented with an array of
symptoms and findings that included joint pain, blood in her urine, chest discomfort and a
positive double-stranded DNA and ANA. A rheumatologist saw her initially and has
followed her care intermittently since the initial diagnosis. However Jane often is unable
to go to her appointments because of her lack of transportation. Because the hospital and
clinic have recently converted to an electronic health record (EHR), only the last nine
months’ worth of appointments are available (the rest are in the paper clinic chart, which
is located in the clinic).
Jane’s physical examination was essentially normal, although James Hall, M.D., thought
she appeared mildly dehydrated. He ordered some intravenous normal saline. Her chest
x-ray was read by James Hall, M.D., as clear and was unchanged compared to one done
at the same hospital just three weeks ago. This x-ray had been done in the ED when Jane
had presented for chest pain, which was ultimately attributed to her lupus. She had been
advised to see her rheumatologist but had not made the appointment. To assist with
diagnosing her chief complaints, multiple blood and urine laboratory tests were ordered
during this visit to the ED.
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The Unfortunate Admission Page 2 of 8
This case study was prepared for the CLARION Interprofessional Case Competition. It was developed as
the basis for discussion in the Case Competition. Information in this case is fabricated/fictitious. Any
resemblance to any healthcare provider is purely coincidental. No part of this publication may be
reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in any form or by any
means-electronic, mechanical, photocopying, recording or otherwise without the permission of the
University of Minnesota.
2008 University of Minnesota Board of Regents. The University of Minnesota is an equal-opportunity
employer and educator. This document is available in alternate formats. For information, contact Barbara
Blalock 612-626-7379

James Hall, M.D., planned to discharge Ms. Nagel after the IV fluids were administered,
but he decided to admit her to the hospital when she told him that her pain was very
similar to the pain that lead to her lupus diagnosis two years ago. He agreed with Jane’s
suggestion that she might be having a flare of her disease because she stopped taking her
medication. James Hall, M.D., told the attending general medicine physician he
recommended she be admitted.
Upon admission to the General Medicine Unit, Grant Thompson, M.D., the intern on call,
obtained some additional history. Jane was also diagnosed as bipolar disorder and had
been admitted nine months ago to a psychiatric unit in a hospital in the same system for a
suicide attempt. Jane lives in a sober house after completed treatment for drug abuse. She
has some biological family but was placed in the foster-care system for six years after
being removed from her mother’s house because of her mother’s drug addiction. Her
older sister also suffers from drug and alcohol addiction. Jane denied using any street
drugs or alcohol.
The complete physical examination done by Grant Thompson, M.D., was normal. Her
white blood count, hemoglobin and electrolytes were all within normal ranges. Grant
ordered multiple other laboratory tests, a urine toxicology screen and a pregnancy test.
He also ordered a psychiatry consult because Jane had told him that she had not been
seeing a therapist or psychiatrist nor taking any medications for her bipolar disorder.
About 9 p.m., Jane’s laboratory work was completed. Her erythrocyte sedimentation rate
was 73 mm/h (normal 0-20 mm/h). The nasal swab for influenza, rapid streptococcal
screen and urine pregnancy test were negative.
Grant Thompson, M.D., briefly discussed the case over the phone with the attending
physician Marc Cash, M.D. They agreed that the likely diagnosis was a flare of her lupus
with a complicating systemic viral or urinary track infection. They decided to restart her
Plaquenil, start prednisone at 20mg per day and consult rheumatology the next day. Grant
wrote this order on his way home at 9:30 p.m.
At 10 p.m. the pharmacy received the orders, and James Miller, Pharm.D., reviewed the
orders. He wrote a note to ask when Jane had her last eye exam. Because he wanted to
follow-up on the patient’s history, James decided not to fill the Plaquenil that night, since
it was written as “qday.” He sent up the prednisone dose.
________________________________________________________________________
The Unfortunate Admission Page 3 of 8
This case study was prepared for the CLARION Interprofessional Case Competition. It was developed as
the basis for discussion in the Case Competition. Information in this case is fabricated/fictitious. Any
resemblance to any healthcare provider is purely coincidental. No part of this publication may be
reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in any form or by any
means-electronic, mechanical, photocopying, recording or otherwise without the permission of the
University of Minnesota.
2008 University of Minnesota Board of Regents. The University of Minnesota is an equal-opportunity
employer and educator. This document is available in alternate formats. For information, contact Barbara
Blalock 612-626-7379

Day Two
Jane had a restless night and did not sleep well. The night nurse found a sleeper chair for
her boyfriend, who had spent the night in her room.
When Grant Thompson, M.D., arrived at 7:30 a.m. the next morning, he reviewed her
vital signs and the morning laboratory work prior to seeing her. Jane had received a total
of 1.5 liters of normal saline since admission.
Her urinalysis showed 10mg/dl ketones, 3 squamous epithelial cells/high power field,
trace leukocyte esterase, 11 WBC/ high power field and mucous. Consistent with a lupus
flare, Jane’s complement concentrations were a C3 of 51mg/dl (90-200), a C4 of 4mg/dl
(15-50) and a CH50 of 22mg/dl (60-144). The sputum gram stain showed mixed grampositive
and gram-negative organisms with less than10 squamous epithelial cells/low
power field. Her blood culture was negative at less than 24 hours. Her urine toxicology
screen was positive for acetaminophen, caffeine and opiates. Grant Thompson checked
the ED note and did not see any note that they had given her opiates for pain.
Grant Thompson, M.D., saw Jane on patient rounds. She was lying in her hospital bed
with her boyfriend. Grant believed Jane looked better than the previous day. The
rheumatologist who saw her later that day also felt that she had a lupus flare with a
concomitant viral infection. Grant and the attending physician discussed Jane’s case.
Both believed she should be ready for discharge by the next day. They agreed she should
be started on levofloxacin for a urinary tract infection. Thompson noted the need for the
antibiotic in his daily documentation.
About 10 a.m. Jo Forsyth, Pharm.D., the pharmacist for the day, called Grant Thompson,
M.D., to ask about Jane’s last eye exam. Grant didn’t know when the appointment was.
After talking with Jo, they decided to start the medication but wrote an order for an
ophthalmologist exam before Jane was discharged. Grant noted the order on the sheets
that he carries in his pocket for each patient to remind himself to order an exam.
At 4 p.m., Grant Thompson, M.D., noticed that no psychiatry note was on the chart. He
asked the nurse, Jackie Billings, RN, if someone from the consult team had seen Jane.
Jackie did not think so. Grant double-checked to ensure the order had been removed by
the Health Unit Coordinator the day before. His check showed the order was removed.
He was certain he had called the psychiatry department and left a message requesting the
consult. Psychiatry staff do not give out a pager number or name of a physician. Instead,
________________________________________________________________________
The Unfortunate Admission Page 4 of 8
This case study was prepared for the CLARION Interprofessional Case Competition. It was developed as
the basis for discussion in the Case Competition. Information in this case is fabricated/fictitious. Any
resemblance to any healthcare provider is purely coincidental. No part of this publication may be
reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in any form or by any
means-electronic, mechanical, photocopying, recording or otherwise without the permission of the
University of Minnesota.
2008 University of Minnesota Board of Regents. The University of Minnesota is an equal-opportunity
employer and educator. This document is available in alternate formats. For information, contact Barbara
Blalock 612-626-7379

they only have a telephone with an answering machine. This is how all consult requests
must be made.
Frustrated by the lack of response by the psychiatry department, Grant Thompson, M.D.,
called the hospital operator to obtain the name of someone to page. He finally managed
to reach the administrative assistant of the psychiatry department. She said the
department didn’t have a record of the consult request. She said they’d had some
problems with the answering machine. She connected Grant with one of the staff
psychiatrists, who recommended that Jane follow-up as an outpatient since she was not
actively suicidal. He gave Grant a phone number to give to Jane so she could schedule an
appointment. Angry about this lapse in care, Grant left after spending 45 minutes on this
issue. In his haste to leave, he forgot to write the order for the levofloxacin.
It was Friday, and Tracey Wells, M.D., was covering for the attending physician Marc
Cash, M.D., that weekend. Marc discussed the patients over the phone with the Tracey
and indicated he thought Jane was improving and she should be discharged tomorrow.
At 6 p.m., Beth Mirrow, LPN, noticed that Jane’s vital signs indicated that she had a
fever of 101.3°F and a pulse of 118 beats per minute. Beth called the on-call intern who
ordered another set of blood cultures and recommended that acetaminophen be given for
the fever. Beth ensured the orders were complete, and Jane’s temperature decreased in
one hour. The on-call intern did not have a chance to write down this information and her
decisions to order the culture and medication and forgot to pass it along to Grant
Thompson, M.D., the next morning
Day Three
Jane felt worse on Saturday morning. After her shift was finished, Kim Franklin, RN,
entered Jane’s morning vital signs at 7:19 a.m., which were a temperature of 101.3°F,
pulse of 140 beats per minute, blood pressure of 105/46, respirations of 30 breaths per
minute, and oxygen saturation of 93 percent on room air. She made a note in the
electronic vitals section that “report was given to AM shift for intervention.”
Grant Thompson, M.D., came in to work on Saturday at 7 a.m. He was hoping to get
finished and leave a little early to enjoy the good weather. Jane was the first person he
saw. Her boyfriend was once again in the bed with her. Jane was sleepy but otherwise her
exam was noted to be normal. It is not clear whether or not he checked her morning vital
________________________________________________________________________
The Unfortunate Admission Page 5 of 8
This case study was prepared for the CLARION Interprofessional Case Competition. It was developed as
the basis for discussion in the Case Competition. Information in this case is fabricated/fictitious. Any
resemblance to any healthcare provider is purely coincidental. No part of this publication may be
reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in any form or by any
means-electronic, mechanical, photocopying, recording or otherwise without the permission of the
University of Minnesota.
2008 University of Minnesota Board of Regents. The University of Minnesota is an equal-opportunity
employer and educator. This document is available in alternate formats. For information, contact Barbara
Blalock 612-626-7379

signs or those from the evening before. Although that information is on the computer,
there is no way to determine who accessed the information.
Len Cameron, LPN, learned about Jane’s temperature from Kim Franklin, RN. This was
his third shift on the Medical/Surgical ward. He had just been hired after working for
three years at a local transitional care facility. Per her standing orders, Len gave Jane
some of the “as needed” acetaminophen as well as an oxycodone for the right-sided chest
pain about which Jane had started complaining. He rechecked her vital signs at 9:11 a.m.
Her temperature decreased to 100.4°F, and her pulse was 123 beats per minute. He saw
that she had blood cultures drawn the previous evening so he did not call the intern and
discuss Jane’s status.
Grant Thompson, M.D., and the covering attending physician, Tracey Wells, M.D.,
discussed Jane’s case at 9 a.m. Grant mistakenly reported yesterday’s vital signs to
Tracey. During their discussion about Jane, Grant realized that he had forgotten to write
the antibiotic order. He was afraid to tell Tracey because she had a reputation for being
very hard on interns. They decided Jane could be discharged, and Grant wrote the orders.
Len Cameron, LPN took the discharge forms and went over them with Jane. She said that
she felt poorly, was having some trouble breathing and really did not want to go. Len
called Grant Thompson, M.D., and told him that “the patient does not feel ready to go
home” but did not convey any other information to Grant or give his opinion. Grant told
Len that Jane had already stayed an extra day because of the mix-up with the psychiatry
consult. Len was unsure when to call an attending physician and didn’t want to get the
intern in trouble. He told Jane that the medical staff felt that she could go home. She was
discharged at 10 a.m. and then took the bus home.
At 11 a.m., Grant Thompson, M.D., finished rounding, writing orders for his patients and
went home. Grant double-checked Jane’s initial blood cultures drawn in the ED. Those
cultures remained negative. He did not see that blood cultures had been drawn the
previous evening. Laboratory tests that do not have reported results (such as the cultures
from the previous night) do not show up in the laboratory section on the new EHR unless
you click “show pending” next to the tests you want to see. Grant is a new user of the
EHR and didn’t know which tab to click. Since it was Saturday, Grant could not make
the ophthalmology appointment. Clinic scheduling is open from Monday through Friday.
Instead, he wrote the phone number for them on Jane’s discharge orders.
________________________________________________________________________
The Unfortunate Admission Page 6 of 8
This case study was prepared for the CLARION Interprofessional Case Competition. It was developed as
the basis for discussion in the Case Competition. Information in this case is fabricated/fictitious. Any
resemblance to any healthcare provider is purely coincidental. No part of this publication may be
reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in any form or by any
means-electronic, mechanical, photocopying, recording or otherwise without the permission of the
University of Minnesota.
2008 University of Minnesota Board of Regents. The University of Minnesota is an equal-opportunity
employer and educator. This document is available in alternate formats. For information, contact Barbara
Blalock 612-626-7379

At 12:15 p.m., the microbiology laboratory technician paged the on-call intern, Jeff
Splaine, M.D. The blood cultures drawn the previous evening were both positive for
gram-negative bacteria, indicating Jane had a bacteremia and was potentially sepsis. The
intern went to the medical unit and quickly looked through Jane’s records to determine
her status at discharge. Concerned for her, at 1 p.m. he called Jane at the Sober House
and asked her how she was feeling. She told him that she was exhausted, coughing and
felt warm and sweaty. Jeff advised her to immediately come back to the hospital.
Jane told him that she had just gotten home and was exhausted. She had no car or ride
and did not have enough energy to walk back to the bus stop. Jeff Splaine, M.D., placed
her on hold and tried to find out if the hospital could pay for a cab. The charge nurse at
the front desk said there was not a mechanism to get that done. Jeff apologized to Jane
and said he didn’t think a cab was possible. He emphasized the need for her to come right
back and go directly to the Medicine Care Unit.
Jane finally arrived at the hospital by bus at 7:15 p.m. and was immediately admitted to
the Medicine Care Unit. She was clearly exhausted, flushed and diaphoretic. At 7:23
p.m., her vital signs were a temperature of 104.7°F, pulse of 149 beats per minute, blood
pressure of 100/38 mmHg, respirations of 40 breaths per minute, and oxygen saturation
of 92 percent. Jeff Splaine, M.D., examined her within a few minutes of her arrival and
quickly concluded that she was in septic shock. He and the nursing staff immediately
transferred her to the Medical Intensive Care Unit and began multiple intravenous
antibiotics including ceftriaxone, vancomycin and levofloxacin.
Jane had not taken any of the medications, including the levofloxacin, given upon
discharge because she was worn out and slightly nauseated.
Jane rapidly decompensated during the next two hours. She progressed into acute
respiratory distress, had to be intubated and placed on a ventilator. Her chest x-ray
revealed new airspace opacities in both lungs consistent with bilateral pneumonia or
acute respiratory distress syndrome. Her blood pressure dropped and multiple
vasopressors were started to maintain her blood pressure.
Despite heroic measures, her blood pressure could not be stabilized. Jane died at 2:12
p.m. the next day.
________________________________________________________________________
The Unfortunate Admission Page 7 of 8
This case study was prepared for the CLARION Interprofessional Case Competition. It was developed as
the basis for discussion in the Case Competition. Information in this case is fabricated/fictitious. Any
resemblance to any healthcare provider is purely coincidental. No part of this publication may be
reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in any form or by any
means-electronic, mechanical, photocopying, recording or otherwise without the permission of the
University of Minnesota.
2008 University of Minnesota Board of Regents. The University of Minnesota is an equal-opportunity
employer and educator. This document is available in alternate formats. For information, contact Barbara
Blalock 612-626-7379

The blood cultures from the evening of the second day of her hospitalization grew
Hemophilus influenzae. Her autopsy revealed bilateral gram-negative pneumonia with
bacteremia and multi-organ failure, likely from septic shock.
________________________________________________________________________
The Unfortunate Admission Page 8 of 8
This case study was prepared for the CLARION Interprofessional Case Competition. It was developed as
the basis for discussion in the Case Competition. Information in this case is fabricated/fictitious. Any
resemblance to any healthcare provider is purely coincidental. No part of this publication may be
reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in any form or by any
means-electronic, mechanical, photocopying, recording or otherwise without the permission of the
University of Minnesota.
2008 University of Minnesota Board of Regents. The University of Minnesota is an equal-opportunity
employer and educator. This document is available in alternate formats. For information, contact Barbara
Blalock 612-626-7379