Systems Failures That Affect Hospitalization

Topic: Nursing
Words: 1350 Pages: 4


Nursing assistants and other hospital workers have an essential role in patient care, and they often discover things before licensed nurses and doctors. It was nearing discharge time for the patient, who had been hospitalized for a moderate respiratory tract infection and COPD exacerbation. When the resident intern observed the patient’s limbs were swollen and decided to do a Doppler ultrasound on one of them. It was also stated that the patient had been found lying down with active convulsions. He did not get his anti-seizure medicine, and the nurse informed neither the doctor nor the pharmacist that it was not in the dispenser. No matter how much a nurse does not want to hear about infections in the hospital, it is preferable to report them and get them treated than to send them home with a high risk of death. Even though the patient got DVT while in the hospital, no pre-hospital prophylaxis was given. CAUTI, pneumonia, a bloodstream infection, and a surgical site infection are the four most often identified Health Acquired Infections (Chrouser & Partin, 2019). DVT is a common problem that can be easily avoided. Cases like this one demonstrate how mistakes can be made and how HAIs are frequently overlooked; they both affect a patient’s well-being and security.



The case study describes the story of Mr. Londborg, who has a long history of outstanding seizure disorder, Hypertension, and COPD. While in extended recovery, the patient now comes to the hospital and is diagnosed with acute exacerbation of COPD. In this case study, the attending physician failed to give the DVT prophylaxis, which made this patient develop DVT while in the hospital. The nurse also did not notify the physician that the drug for anti-seizure for the patient was not available in the automatic dispensing system (Sedki et al., 2018). Errors might arise if there is no clear communication between the patient and all caretakers. The patient’s safety was jeopardized because the nurse neglected to communicate with the doctor and the patient. Health workers need to be taught communication skills based on the hospital setting and its importance in reducing errors in the future. The electronic health record to be improved, especially in the pharmacy, to alert the pharmacist when the drug keyed in is out of stock. Maybe the drug was available to train the health workers on using the automatic dispensing system, but the nurse did not know how to operate the system.

Legal Ramifications

In this case, the nurse’s mistakes and the physician who met the patient for the first time on admission might have serious legal ramifications. The patient had a seizure due to the nurse not giving the patient the medicine for seizures. The nurse did not inform the pharmacist and doctor that the patient’s medication was not in the automated dispensing system. DVT prophylaxis was not given because the patient would be in bed for a long time, and the resident intern discovered this when the patient told him he was feeling a swollen limb. As a result, they might face allegations of carelessness in their duty. Medical professionals are obligated to provide patients with all relevant information on their medical treatment or procedure. Because the nurse and physician omitted to do so, they may be held liable for medical malpractice. Of the RN and physician’s mistakes in this instance, the hospital’s reputation is at risk because it is accountable under the contributory infringement principle for its employees’ acts (Sedki et al., 2018). Both the nurse and the physician might lose their license to practice medicine due to the mistakes made in this case.

Financial Repercussions

The healthcare sector loses billions of dollars each year because of the tens of thousands of fatalities caused by hospital-acquired illnesses. The hospital might suffer several financial ramifications due to the blunders in this case. DVT prophylaxis was not given by the patient’s physician, which resulted in the patient having to pay for an ultrasound that might have been avoided if he had been put on it. Since of this, the patient had a seizure that necessitated him to get ahead CT scan and shoulder and elbow x-rays because the nurse failed to administer anti-seizure medicine. Because of the actions of the nurse and physician, financial penalties may have been averted in this situation (Seegräber, 2018). The mistakes directly impact the hospital; as a result, if Medicaid or any other medical insurance covers this patient, the insurance may not cover the patient’s readmission to the treatment center of infection following discharge. The patient would be saddled with additional debt as a result.

Reporting Systems and Communication Strategies

As a result of her carelessness, the patient’s health and the hospital were in jeopardy. In order to ensure that nurses’ responsibilities are carried out by excellent nursing care and the ethical requirements of the profession, the Code of Ethics for Nurses, including Interpretive Statements, was produced. The nurse violated the command structure by failing to tell the patient of her suspected infection. Chain of command refers to an authority framework developed to handle clinical, administrative, or even other patient safety concerns. This is done by allowing healthcare professionals to communicate an issue of concern via responsibility and authority till a resolution is achieved (Chrouser & Partin, 2019). Patient complications resulted from the nurse’s failure to follow protocol and consult with the proper authorities. Using the chain of command in this scenario, starting with the pharmacist and physician’s communication, may have prevented the patient from having a convulsion. Because the nurse failed to raise this concern with the patient’s doctor, the patient suffered from a breakdown in communication and subpar care. When it comes to delivering the most excellent possible care and safety for patients, the chain of command may be helpful (Sedki et al., 2018). The mistake highlighted in this situation can be prevented if patient advocacy and effective communication are used.

Hand Washing

Alcohol-based hand rubs and anti-microbial soap are suitable media for decreasing and avoiding cross-contamination of micro-organisms, according to the Centers for Disease Control 2002. If hands are filthy, soap and water must be used to clean them before using alcohol-based hand sanitizers (Pugliese & Favero, 2018). Pre- and post-glove decontamination, contact with equipment and patient skin, insertion of invasive devices like catheters, and contact with mucous membranes or bodily fluids are all examples of situations in which hand decontamination is needed. In order to ensure compliance, healthcare staff should be instructed on proper handwashing practices and have someone at the entrance gate remind them to wash their hands. The use of hand sanitizer should be emphasized to patients as well. The handwashing station should be located where patients and healthcare workers are more likely to use it. Hand sanitization should be a top administrative priority, and healthcare staff should have easy access to alcohol-based hand massages.

There are several ways to enhance healthcare workers’ handwashing compliance and reduce rates of hospital-acquired infections, including education, written materials, and ongoing feedback on performance. According to Haque e al. (2018) MRSA infections were more common in the neonatal intensive care unit (NICU) if compliance with hand hygiene was less than 80%, even when extra preventive measures were implemented. Based on FMEA results, a multi-disciplinary task force initiated corrective activities, including placing hand sanitizers to coincide with the workflow, teaching patients and visitors about using hand sanitizers and developing unit-specific interventions. MRSA rates were effectively reduced due to these initiatives, which raised the level of compliance among healthcare workers (Haque e al., 2018). Compliance, on the other hand, is more of a problem. All hospital-acquired infections should be eliminated. The importance of good hand hygiene cannot be overstated. There are several reasons nurses must be attentive to their hand hygiene. They are role models for visitors, patients, and other healthcare team members. Illnesses can be prevented, and the number of patients who have hospital-acquired infections is reduced by practicing good hand hygiene. As a result, patients spend less time in the hospital, and the treatment they get is of higher quality and safer.


Chrouser, K. L., & Partin, M. R. (2019). Intraoperative disruptive behavior: The medical student’s perspective. Journal of Surgical Education, 76(5), 1231-1240.

Haque, M., Sartelli, M., McKimm, J., & Abu Bakar, M. B. (2018). Healthcare-associated infections – an overview. Infection and Drug Resistance, 11, 2321-2333.

Pugliese, G., & Favero, M. S. (2018). CDC draft guideline for hand hygiene. Infection Control & Hospital Epidemiology, 22(12), 787-787.

Sedki, M., Mendez, J., Bruer, S., & Levine, D. (2018). The importance of teamwork in healthcare for effective communication and care of older adults. Journal of Interprofessional Education & Practice, 1(2), 71-72.

Seegräber, M. (2018). Disease-related direct and indirect health costs for patients with chronic urticaria.

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