About the Hospital Prairie Regional Medical Center (PRMC),  located in central Kansas, is a 245-bed hospital that offers a  comprehensive range of inpatient and outpatient medical services to  residents of central Kansas

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About the Hospital

Prairie Regional Medical Center (PRMC),  located in central Kansas, is a 245-bed hospital that offers a  comprehensive range of inpatient and outpatient medical services to  residents of central Kansas. The medical staff of PRMC consists of more  than 125 physicians and dentists representing a number of specialties,  including the following:

• Comprehensive cardiac care
• Neurosciences
• Women's health
• Emergency medicine, including a 24-hour trauma center
• Rehabilitation

Among the specialized units and facilities at PRMC are the following:

• Dedicated women's unit
• Skilled nursing facility
• Comprehensive inpatient rehabilitation unit accredited by Commission on Accreditation of Rehabilitation Facilities International
• Community resources center
• Laboratory accredited by the College of American Pathologists and American Association of Blood Banks
• Women's imaging center
• Wound care unit

PRMC is fully accredited for all services surveyed by The Joint Commission.

The Situation

Felix, a 68-year-old man, presented to  PRMC with a peptic ulcer and underwent abdominal surgery (a diagnostic  laparotomy). He was admitted to the patient tower for an anticipated  four-day monitoring and recovery stay after his surgery, which was  performed without any complications. Other than the recent operation,  Felix has been in relatively good health for his age, but does have  diabetes and wears hearing aids in both ears.

Renee, a registered nurse, was assigned  to Felix's care during his recovery. She would be able to monitor and  care for Felix for his entire recovery because she works a unique  schedule of five days on, five days off, which was specifically arranged  for her starting three years ago. Renee works 12-hour days from 7:00  a.m. to 7:00 p.m.

By day 3 of Felix's recovery, he began  to notice that communicating with Renee had become somewhat difficult  compared with the previous two days. She was short in response to his  and his family's questions and noticeably yawned when she came in for  routine checks. His wife also noticed that Renee had begun to take  markedly longer to respond to his call lights. Later that evening before  shift change, Renee took his vitals as she had done the previous two  days. Everything appeared normal, so she returned to her other patients  on the floor for one last check-in.

By day 4, everything had changed. Renee  returned to her fourth shift at 7:00 a.m. to find that Felix's status  was declining. He had a temperature of 102 degrees Fahrenheit, his blood  pressure was low, and he had difficulty breathing. Renee tried to  quickly get caught up with all that she had missed throughout the night,  but she was on edge when someone mentioned that the temperature spike  likely occurred during her previous shift and was missed by the nursing  staff. She knew that she was the last person to sign off on Felix's  chart before the night-shift transition and could not help but feel an  overwhelming sense of guilt.

What Happened?

Renee now acted through a rush of pure  adrenaline, as she knew she needed to quickly get to the bottom of what  had happened. She retraced her steps throughout his entire course of  care, and then it hit her. Amid her fatigue and constantly busy floor  schedule the day before, she had forgotten to come in prior to her last  vitals check to remove his hearing aids. She had taken his tympanic  temperature with both hearing aids still in when the standard  recommendation is to remove hearing aids and wait 10 minutes before  taking a temperature. When Renee realized her mistake, she rushed to  find Pam, the new nurse manager, because she knew she had a duty to be  transparent with her care. She did not know if this error was the exact  cause, but Pam needed to be aware of it. After all, she thought, “I'm  human, I make mistakes.”

Renee was incredibly nervous about  explaining to Pam what had happened because she knew that Pam had never  liked Renee's work schedule, which had been agreed to before Pam was  hired. However, Pam had been willing to accommodate Renee's request as  long as no patient complaints could be related to her long hours. Pam  was hired into a nursing shortage in the hospital and was therefore in a  staffing bind regardless of Renee's schedule. Also, she did not want to  ruffle too many feathers because she was so new, so she was willing to  try unconventional staffing rotations if her employees wanted them.

Pam then met with Bruce, the grievance  coordinator, to pass along this information. Pam had simultaneously set  forth an investigation to determine how the infection had been missed  under their care. After the investigation revealed that the temperature  spike should have been detected under Renee's care, Pam and Bruce went  to meet with Felix's wife. Felix's wife complained that Renee had been  visibly drowsy, late to call lights, and unpleasant the day before, but  when she knew that Renee had incorrectly taken her husband's vitals, she  immediately threatened to file a formal negligence complaint with the  Kansas Insurance Department and the CMS Office of the Regional  Administrator in Kansas City, Missouri, if Renee was not fired  immediately.

Pam returned to her office to discuss  the proper course of action with Bruce. She had several considerations  and a combination of possible outcomes. First, this occurrence was the  first documented complaint against Renee since Pam had been manager, and  Renee had been a highly regarded nurse for the eight years she had been  with PRMC. Pam liked to get to know her employees, and so she also knew  that Renee and her husband were struggling financially and had three  children to support. Renee's unconventional schedule had been developed  to offset her husband's work schedule so that one parent could always be  home with their children because they could not afford childcare.  However, she too had noticed Renee coming to work midrotation looking  exhausted and not as cheery as she was on the first few days of her  rotation. Next, Pam had to consider the implications of the formal  grievance and how it would affect her department and ultimately the  hospital. Felix's increased length of stay would already prevent the  hospital from being reimbursed for his care, but Pam had to consider  whether firing an employee over a single mistake was at all justified to  further protect the reputation of the hospital.

Questions for Discussion 

• How should Pam handle the complaint by the patient? What is the danger of disregarding the patient's complaint?
• Should Pam consider changing Renee's shift schedule? Are there any  limits to the number of shifts or hours that nurses should work? Do you  think there should be?
• How should Pam respond to Felix's wife's demand that Renee be fired?
• Should this situation be addressed by a QI team, or is this simply an unfortunate situation arising from a troubled employee?
• .Could this situation have been avoided if the organization's  human resources management systems had been different? If so, what HR  systems might have played a role in this situation?e