Errors

What errors were made?

1. The physician assistant left an order to continue the home dose of Lisinopril 20 mg daily, instead of stopping it or lowering the dose.
2. The physician signed off on the incorrect blood pressure order. She appeared busy and distracted during the encounter, which may have led to the error occurring.
3. The certified nurse's aid left the patient sitting up at the bedside by herself, despite an order that she should not be up without assistance. This did not directly lead to the fall, but would be considered a "near miss".
4. The nurse gave the Lisinopril despite Mrs. Cooper's blood pressure being lower than the medication holding parameters.
5. The nurse also left all the bedside rails up. This did not directly lead to this fall, but leaving bedside rails up has been shown to increase fall risk in hospitalized patients and it is recommended not to do this.
6. The physical therapist left Mrs. Cooper unassisted at the bedside.
7. Mrs. Cooper was complaining of dizziness, and the physical therapist did not alert the nurse.
8. She also did not leave her with a call bell to contact the nurse or ensure that she was wearing non-slip socks.

These errors, made by multiple people throughout the hospital stay, lead to Mrs. Cooper's fall and hip fracture. The patient and family are, understandably, upset, and want to meet with the medical team to understand how this error occurred. The family will meet with the physician, physicians assistant, nurse, physical therapist and CNA.