Blog, theater, hospital

Bad discharge planning and emergency readmission

It's not the inadvertent errors that cause major problems, but the secrecy covering them up

Everybody makes mistakes during medical procedures. To err is human.

But if they aren’t explained and follow up set in place to monitor the  patient for side effects including after discharge, then a small problem can quickly become a life threatening one.

A young woman we will call ‘Annie” had a dilatation and curettage at a hospital.

During the procedure, her uterus was unintentionally perforated. The surgeon was aware of this error, but the potential risks were not clearly explained to the patient.

Annie was discharged early the following day in a rush, as the hospital needed to free up its beds. There was no discussion of potential problems to watch out for.

No GP or nursing follow-up was organised.

A small problem that wasn't properly managed, can very quickly become a life threatening one

A week after surgery, Annie developed a raging fever. 

She range her woman friends, who came around to check up on her. Concerned about her sudden deteriation and unable to understand the cause, they decided called an ambulance.

Annie was taken to the Emergency Department of the same hospital, where she had had a D & C.

Nurses took her temperature. It was over 40 degrees. Her blood pressure was low, her pulse thready and weak. Her abdomen was also hard and swollen.

An Emergency Doctor quickly assessed her and she had an urgent CT of her pelvis. 

Annie was diagnosed with a severe infection in her abdomen called peritonitis. She was rushed to theatre and her abdomen opened up.

Surgeons found the small nick into her bowel, which had caused faecal matter to slowly leak into her abdomen cavity. This was being absorbed into her bloodstream, causing septic shock.

The surgical team had to physically pull her bowel out from her abdomen cavity, wash it all down, find the nick, suture it up, then replace the bowel back in her abdomen.

She was given cardiac drugs and fluids to get her blood pressure up and strong antibiotics to overcome the infection.

After her emergency surgery, Annie was taken to Intensive Care and treated for septic shock. Two days later she was discharged to a surgical ward.

Annie subsequently spend several weeks in hospital with open abdomen drains, regular and painful dressings and continuous intravenous antibiotics.

Secrecy also means procedures are not changed to prevent errors reocurring

There was no assessment of this error or attempt made to prevent it from recurring.

The surgeon was not held accountable for inadvertently nicking the patient’s bowel.

The hospital was not held accountable for discharging the patient despite her being at high risk of developing a life threatening infection.

No apology was given to the woman for her life being put at risk, or her time off work to recover.

Wikihospitals 2014

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