North Shore Hospital report - New Zealand Doctor

Opinion 07HDC21742At 1.45pm a nurse and orderly arrived to shift Mrs E to another room in the ward.They suggested that she walk to the new room, carrying her intravenous fluid bag,oxygen mask and a paper bag with her belongings. However, when she was in thecorridor, another nurse said that her room was not ready. Mrs E said, ―Everyonedisappeared and I stood there waiting. After 5 minutes they happily pushed my emptybed and I followed.‖The nursing notes indicate that Mrs E was offered a nebuliser and pain relief at 2pm,but declined this. Mrs E told the nurse that she preferred to use her own inhalers ratherthan a nebuliser. Referrals to a social worker and the needs assessment team weremade in preparation for Mrs E to leave the following day.Mrs E experienced considerable delay in reattaching her intravenous fluids after shechanged rooms. An hour after she moved, she found that her intravenous site wasswollen and leaking and her bed linen soaked. Her call-bell went unanswered. When anurse noticed the problem she told Mrs E that the charge nurse would reinsert thecannula. A social worker arrived to talk to Mrs E, noted the leaking intravenous siteand reminded the nursing staff about it. She was told that all the staff were too busy tore-site it at that time. The cannula was eventually re-sited by the charge nurse and theintravenous fluids restarted at about 5pm.The afternoon shift registered nurse recorded that Mrs E was concerned about herhome situation. The night staff recorded that Mrs E ―appeared to be comfortableovernight‖ and that her intravenous fluids finished during the shift. However, Mrs Erecalls that she coughed as badly during the night as she had when first admitted. Shewas sweating, and needed to sit up all night because she was having trouble breathing.At 8am on Friday 19 October, Mrs E‘s vital signs were again assessed and noted to besatisfactory, and her intravenous fluids finished. The laboratory technician who tookher blood sample that morning told her that there were no patient labels in her file andthat this was ―par for the course‖.Around this time a nurse arrived to give Mrs E her medication. The nurse noted thatshe was coughing and breathless, and asked why she was not using her nebuliser. MrsE explained that she had not been given a nebuliser. The nurse fetched a salinenebuliser and mask, which eased her breathlessness and cough. Mrs E asked if shecould have a saline nebuliser to take home, but was told that she would have to buyone. 47When Mrs E was seen later that day by a needs assessor about dischargearrangements, she described her home situation, which was stressful because herhusband was unwell and receiving radiotherapy. The needs assessor gave Mrs E a47 The DHB subsequently clarified that it does not lend nebuliser machines, and it was correct for thenursing staff to suggest to Mrs E that she access one privately. As a result of these events, aninformation sheet about the supply of these machines is being prepared for staff to give to patients ondischarge.April 2009 29