A series of unfortunate events

Abstract

Mr. B presents to the ED with a 4 day history of dyspnea. He is a smoker, and was diagnosed one year ago with systolic heart failure (NYHA II). He has a history of hypertension, and is on enalapril 10mg PO BID and labetalol 200mg PO q12h. Physical exam reveals bilateral crackles and moderate peripheral edema. The ED physician orders a chest X-ray, and observes signs of pulmonary edema. A decision is made to admit Mr. B, but it proves difficult to diurese him, and the decision is made to insert a Foley catheter on the ward. On the third night of his stay, he complained to a member of the cleaning staff of severe pain in his right leg. The staff member subsequently notified the nurse, who was able to contact the resident on call. A bedside ultrasound was performed, and confirmed the presence of a DVT. The resident also noted that the patient had not been started on DVT prophylaxis. After morning rounds the patient was started on anticoagulation, and his pain resolved within a few hours. Now on his 4th day in hospital, the nurse noted that Mr. B was now febrile, and that he was producing cloudy urine. The catheter is removed and Mr. B is started on empiric antibiotic therapy, and a few days later the infection resolves. However, Mr. B spent 5 extra days in hospital and was discharged feeling extremely displeased with his care. You are the hospital director of quality improvement, and have been asked to review the case and suggest solutions.