Frail, elderly people and busy, error prone hospitals are a bad combination

Constantly changing nursing shifts,  pressure for beds and rushed discharges. The trigger for errors is always there. And the longer elderly people stay in hospital, the higher the risks of errors are.

A slight, eighty year old woman called Daphne was admitted to hospital after suffering a stroke.

After spending several weeks of treatment, the doctors declared she was stable.

Daphne was then assessed for a rehabilitation unit.

Rehabilitation units often demand 'perfect' patients. However, at eighty, no one has perfect vital signs.

The hospital desperately needed the bed and were keen to discharge Daphne.

She wanted to get out of the impersonal hospital ward and into a more relaxed environment.

However, her blood pressure was consistently on the low side. Daphne was taking blood pressure medications.

However the rehab unit’s guidelines were extremely strict. Unless Daphne had ‘perfect’ vital signs she could not be accepted.

The senior ward nurse asked a junior doctor to write up intravenous fluids, to quickly raise Daphne’s blood pressure to ‘normal’ range.

However, Daphne’s blood pressure remained borderline. More fluids were given. Nurses were also told to encourage her to drink plenty of water. The elderly lady was given one litre jugs of water and told to drink as much as possible.

Despite this effort, Daphne’s blood pressure remained low. The rehabilitation team insisted that should couldn’t be accepted to rehab. Hospital staff continued to push fluids. Blood pressures were done every four hours. And more bags of IV fluid were put up.

No blood tests were done to check Daphne’s fluid and electrolyte levels.

After five days of continuous fluids both IV and oral, a nurse found Daphne having seizures, on her bed.

A code blue was called, and the emergency team rushed in. Blood tests were quickly done.

They revealed that her sodium levels were very low. Low sodium levels can increase the risk of seizures. On review, the doctors diagnosed the cause of her low sodium as being related to excess fluids.

A lot of petty rules, but not much common sense

Daphne was immediately put on a fluid restriction of 500 mls a day.

All her intravenous fluids were ceased.

Her rehabilitation bed was cancelled. Daphne spend another week in a noisy, impersonal, error prone hospital.

© Wikihospitals 2015

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