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CASE STUDY

CASE STUDY. Dr Byth. An Inpatient Fall. 55 yr male Routine Booked Admission Attended HEAPS clinic ETOH 6 beers / day Smoker 20/day Thoracotomy Post op epidural - good pain relief ICC slight air leak Progressed well till……. Day 3 Post Op. Morning Mobile Showered self Compliant

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CASE STUDY

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  1. CASE STUDY Dr Byth

  2. An Inpatient Fall • 55 yr male • Routine Booked Admission • Attended HEAPS clinic • ETOH 6 beers / day • Smoker 20/day • Thoracotomy • Post op epidural - good pain relief • ICC slight air leak • Progressed well till…….

  3. Day 3 Post Op • Morning • Mobile • Showered self • Compliant • Late Afternoon / Evening • Restless agitated • Pulling out lines • Packed his suitcase ready to leave • Threatening staff / aggressive

  4. Pre Fall • 18:15 AMO and Pain team contacted • 19:00 Admits regular ETOH intake • 19:45 Reviewed by RMO • Admits 60-70 grams daily 15+years • PRN diazepam charted ETOH score 1 nil – nil administered based on score • Patient compliant • 20:20 Increased agitation……the fall……

  5. 20:20 pm • Pt increasingly agitated • Three nurses present • Other patients in room leave • Nurse leaves room to call security / RMO • Requested assistance immediately • Patient punches out screen & climbs on sill • Attempts made to coax pt back

  6. The Fall • Patient Fell from 3rd floor window • Arrest team call • Poor lighting resulting in difficulty in finding pt • Patient deceased

  7. Internal Processes • Report Type – System Analysis RCA • Reported to Clinical Governance Unit • Internal Process – RCA

  8. Actions • Ward safety • Review design of windows • Location of duress buttons • Preoperative identification of Risk • Recognition of risk of ETOH withdrawal

  9. Actions……continued • Management of Acute Delirium • Education and training of ETOH withdrawal • Use of benzodiazepines in ETOH withdrawal • Documentation • Reinforce importance of documentation of time when entering into patient notes • Ensure all documentation on admission is reviewed

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