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Quality of care and pressure wounds.

Pressure ulcers have one of the highest occurrence rates in nursing home settings. Given the aging population, increasingly fragmented care, and nursing shortages, the incidence of pressure ulcers is expected to continue to rise. There has been a long-standing belief among nursing experts that bedsores are associated with poor, or no nursing care, not with the disease and many clinicians believe that pressure ulcer development is a breakdown in the healthcare team's cooperation and skill.

Pressure sores of stage IV occur when deep soft tissue, bone material, muscles, and tendons are exposed to infecting organisms and are caused by factors such as friction, pressure, and shear that cut off blood supply to the skin. Without proper treatment, this loss of blood flow can cause skin death and wound formation. The pressure ulcers can eventually spread to the bones if left untreated. This type of pressure ulcer is associated with major infectious complications including soft tissue infection and osteomyelitis (acute bone infection).

Nursing Home Failures Led to Untreated Infections and Death

Case Summary:

This case involves a 40-year-old in male a monogamous long-term relationship with his husband. In late 2015, he sought primary care for myalgia, skin rashes, and sore throats. Over the next five years, he visited his primary doctor frequently with complaints of depression and anxiety, skin rashes, stomach pains, headaches, and herpes breakouts. In four years under his primary's care, he complained of diarrhea, fatigue, and persistent yeast infections. The patient was tested for hepatitis and various lab tests, but not HIV. HIV testing was eventually conducted in 2020, and he was diagnosed as positive. He began treatment for HIV at a different clinic and was subsequently diagnosed with Kaposi's sarcoma in addition to full-blown AIDS, and treatment with Biktarvy ® was initiated.

Case theory:

Failure to Diagnose a Life-Threatening Infectious Disease

Case Summary
This case involves a 53-year-old female who presented to a urogynecologist with a chief complaint of uterine prolapse. She was diagnosed with symptomatic stage 2 uterine prolapse and underwent a laparoscopic-assisted vaginal hysterectomy with anterior repair and no noted complications. She was discharged to home on postoperative day one. On postoperative day two, the patient reported worsening pain and lethargy. On day three, the patient called the surgeon’s office reporting increased malaise and lethargy. She was told that the cause was likely gas related and was recommended to take GasX as a solution. On postoperative day four, she again called the office reporting a low-grade fever with chills and reiterated the previous and worsening complaints. She was not called into the office. On the fifth day after surgery, the patient reinstated her continued complaints along with abdominal distention. She was instructed to go to the emergency room. She suffered a syncopal event prior to arriving to the ER. Upon CT examination, the patient was found to have a fluid collection in the lower abdomen and was subsequently taken for surgery where a small bowel enterotomy with active sulcus leaking was discovered. The patient required resection of 30 cm of small bowel that necessitated a prolonged hospital stay.
Case Theory
Enterotomy is the surgical incision into an intestine. It may be purposeful or a complication of an abdominal surgery, such as exploratory laparotomies or hysterectomy. Intentional enterotomy is performed to remove an obstruction or foreign body from the intestine. Inadvertent enterotomy in abdominal surgery is widely underreported. Due to the limited field of vision, the incidence of enterotomy in laparoscopic surgery may be greater than that during an open procedure and may go unrecognized.
Injuries of the bowel during laparoscopic gynecological operations are well recognized. Due to the possible catastrophic complications resulting from bowel

Hysterectomy Injury Results in Bowel Resection

Case Summary
This case involves a 50-year-old male with no pertinent past medical history who experienced a syncopal event whilst running for the bus. Upon admission to the ER, he was found to be in Afib with rapid ventricular response. Lab studies were notable for hyperthyroidism and thyrotoxicosis. The consulted cardiologist suggested likely thyroid etiology as the cause of arrhythmia and recommended a referral to endocrinology. Under the care of hospital practitioners, antithyroid medications were prescribed. The patient was cardioverted although he remained in Afib. Approximately 7 days later a brain MRI noted a stroke which left the patient with severe neurological deficits. He was eventually diagnosed with thyroid storm.
Case Theory
The most common cardiac complication of hyperthyroidism is atrial fibrillation (Afib), affecting approximately 15% of patients. The cause of Afib is an abnormality of the electrical system of the heart characterized by an irregular heartbeat resulting from the two upper heart chambers not contracting properly. Atrial fibrillation with rapid ventricular response (RVR) is one of the most dangerous forms of arrhythmias that significantly increases an individual's chances of having a heart attack, stroke, and irreversible organ damage. This critical condition can often be found as an exaggerated presentation of thyroid storm (thyrotoxicosis). A thyroid storm is a life-threatening complication of hyperthyroidism that involves multiple systems. Most of these patients require oral anticoagulation to prevent thromboembolic complications. In co-existing Afib with thyroid storm, the risk of cardiac and neurological events is high. Thyroid storm is estimated to have a mortality rate of up to 25% despite advances in treatment and supportive measures. Therefore, early recognition and aggressive resolution of the condition is critical. Thyroid storm coexisting with ischemic stroke increases mortality risk. Hemodynamic management of the disease

Failure to Identify Thyroid Storm Results in Neurological Deficits

Case Summary
A 42-year-old male with a history of diverticulitis was referred to the emergency department by his family physician after complaining of coughing, shortness of breath, and an oxygen desaturation of 60%. Upon admission to the hospital, the patient was diagnosed with pneumonia, intubated, sedated, and given antibiotics. In the following week, a pulmonologist referred the patient for exploratory surgery for possible ileus perforation. The general surgeon reviewed the CT imaging and found no signs of free air or perforation. On the same day, the general surgeon determined that due to the growth of gram-negative rods of E. coli identified during a recent thoracentesis, perforation may be possible. One week later, a CT scan of the abdomen and pelvis with IV contrast revealed a collection of free air and fluid in the small intestine, but it was unclear whether this was a sign of perforation. As a result of the patient's unstable respiratory status and sepsis, drains were placed by the general surgeon. A surgeon's partner then took over the patient's care. Due to the patient's unchanged clinical condition, the first general surgeon returned to care and performed an ex-laparotomy that revealed a perforated bowel. An urgent operative repair was performed, and the patient was transferred two days later to another hospital. The patient died the next day. ARDS, septic shock, and perforated diverticulitis are listed as the immediate causes of death on the patient's death certificate.
Case Theory
Perforation of the gastrointestinal tract may be suspected based upon the patient's clinical presentation. The diagnosis becomes obvious through a report of extraluminal "free" gas or fluid collection on diagnostic imaging. Surgical consultation should be pursued early in any patient with abdominal pain and signs of clinical deterioration. An exploratory laparoscopy is often performed to obtain information that is not available via clinical diagnostic methods. Once the

Delay in Surgical Repair Leads to Patient Death

Case Summary
This case involves a 52-year-old patient who was admitted to the hospital on May 8 for evaluation of abdominal pain and constipation. Imaging was ordered two days later with the findings being consistent with probable colonic bowel obstruction. Despite the suspicion, the patient was discharged home. Two days later she presented to a different hospital and was admitted for management of possible bowel obstruction. The obstruction was later confirmed by imaging. A general surgeon was consulted who chose to delay surgery, watch, and wait. At that time, the surgeon tentatively scheduled surgery for May 25th if her condition did not improve. On May 23, the patient’s condition worsened. The following day, the patient’s condition continued to deteriorate. Her pain was reported as 10/10. The physician was not alerted to the change in status. It is alleged that the nurses failed to consider further workup and delayed the escalation of care. The patient was later found unresponsive with vomit on her gown, and she died. An autopsy revealed bowel perforation.
Case Theory
The types of changes in a patient’s condition that should be reported depend on the patient’s situation and stability with attention to any standing physician orders.
Due to the vast amount of patient changes, it is not possible to list every change in a patient’s condition that should be reported. However, aside from the changes in the chief complaint and related symptoms, the following are some of the major changes that nurses should immediately report.
Adverse drug reactions, agitation, bleeding, blood glucose levels, blood pressure, fever, bruising, rash or skin color changes, chest pain or cardiac rhythm change, altered mental status, loss of consciousness and confusion, labored respiration or low oxygen saturation, falls, facial droop and slurred speech, extreme fatigue, loss of body movement or function, weakness, muscle spasms, neurological changes, pain level, skin breakdown

Nursing Home Failures Led to Untreated Infections and Death

Failure to Diagnose a Life-Threatening Infectious Disease

Hysterectomy Injury Results in Bowel Resection

Failure to Identify Thyroid Storm Results in Neurological Deficits

Delay in Surgical Repair Leads to Patient Death

Nursing Staff’s Failure to Notify Physician Results in Patient Death