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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?