Setting: Physician speaks to a family member in tears
Betty Edwards: I can't believe this could happen. He was doing so well. He was making such good progress after his stroke. I don't understand how he could suddenly die from a blood clot.
Voice over: Each of the following team members possess some information about the patient's condition that might have led to a different outcome.
Physiotherapist: I noticed for the last 2 physio sessions that he seemed to be having more trouble walking. His right leg seemed to be hurting.
Pharmacist: I noticed Mr. Edwards wasn't taking any prophylactic anticoagulants to prevent DVT. I was going to mention it to the team.
Nurse: Over the weekend I called the on call physician. Mr. Edwards had been getting more anxious and seemed to be hyperventilating and was quite diaphoretic. The on call resident gave him a benzodiazepine to help him sleep. I think he was still anxious though as his pulse was still 130. I didn't want to disturb the resident again about it in the middle of the night.
Resident 1: Mr. Edwards is anxious and doesn't really like hospitals. The nurse called me about him, again, so I prescribed him a sedative. Guess it worked because I didn't hear back.
Setting: Handover at nursing station with 2 residents, 2 nurses, physiotherapist and pharmacist
Resident 2: Ok, you've got 12 inpatients. Let's see, in room 1, Mr. Edwards, had a stroke on June 3rd. He's been here for 2 weeks. He's waiting for a rehab bed which may be available at the end of the week.
Nurse: Ok, bed 2?
Concluding facilitation question: How might this clinical outcome have been avoided?