About the Hospital Prairie Regional Medical Center (PRMC), located in central Kansas, is a 245-bed hospital that offers a comprehensive range of inpatient and outpatient medical services to residents of central Kansas. The medical staff of PRMC consists of more than 125 physicians and dentists representing a number of specialties, including the following:

• Comprehensive cardiac care

• Neurosciences • Women’s health

• Emergency medicine, including a 24-hour trauma center

• Rehabilitation Among the specialized units and facilities at PRMC are the following:

• Dedicated women’s unit

• Skilled nursing facility

• Comprehensive inpatient rehabilitation unit accredited by the Commission on Accreditation of Rehabilitation Facilities International

• Community resources center

• Laboratory accredited by the College of American Pathologists and American Association of Blood Banks

• Women’s imaging center

• Wound care unit

PRMC is fully accredited for all services surveyed by The Joint Commission.

The Situation

Felix, a 68-year-old man, presented to PRMC with a peptic ulcer and underwent abdominal surgery (a diagnostic laparotomy). He was admitted to the patient tower for an anticipated four-day monitoring and recovery stay after his surgery, which was without any complications. Other than the recent operation, Felix has been in relatively good health for his age, but does have diabetes and wears hearing aids in both ears.

Renee, a registered nurse, was assigned to Felix’s care during his recovery. She would be able to monitor and care for Felix for his entire recovery because she works a unique schedule of five days on, five days off, which was specifically arranged for her starting three years ago. Renee works 12-hour days from 7 am to 7 pm. By day 3 of Felix’s recovery, he began to notice that communicating with Renee had become somewhat difficult compared with the previous two days. She was short in response to his and his family’s questions and noticeably yawned when she came in for routine checks. His wife also noticed that Renee had begun to take markedly longer to respond to his call lights. Later that evening before shift change, Renee took his vitals as she had done the previous two days. Everything appeared normal, so she returned to her other patients on the floor for one last check-in. By day 4, everything had changed. Renee returned to her fourth shift at 7 am to find that Felix’s status was declining. He had a temperature of 102 degrees Fahrenheit, his blood pressure was low, and he had difficulty breathing. Renee tried to quickly get caught up with all that she had missed throughout the night, but was on edge when someone mentioned that the temperature spike likely occurred during her previous shift and was missed by the nursing staff. She knew that she was the last person to sign off on Felix’s chart before the night-shift transition and could not help but feel an overwhelming sense of guilt.

What Happened?

Renee now acted through a rush of pure adrenaline, as she knew she needed to quickly get to the bottom of what had happened. She retraced her steps throughout his entire course of care, and then it hit her. Amid her fatigue and constantly busy floor schedule the day before, she had forgotten to come in prior to her last vitals check to remove his hearing aids. She had taken his tympanic temperature with both hearing aids still in when the standard recommendation is to remove hearing aids and wait 10 minutes before taking a temperature. When Renee realized her mistake, she rushed to find Pam, the new nurse manager, because she knew she had a duty to be transparent with her care. She did not know if this error was the exact cause, but Pam needed to be aware of it. After all, she thought, “I’m human, I make mistakes.”

Renee was incredibly nervous to explain to Pam what had happened because she knew that Pam had never liked Renee’s work schedule, which had been agreed to before Pam was hired. However, Pam had been willing to accommodate Renee’s request as long as no patient complaints could be related to her long hours. Pam was hired into a nursing shortage in the hospital and was therefore in a staffing bind regardless of Renee’s schedule. Also, she did not want to ruffle too many feathers since she was so new, so she was willing to try unconventional staffing rotations if her employees wanted them. Pam then met with Bruce, the grievance coordinator, to pass along this information. Pam had simultaneously set forth an investigation to determine how the infection had been missed under their care. Once the investigation revealed that the temperature spike should have been detected under Renee’s care, Pam and Bruce went to meet with Felix’s wife. Felix’s wife complained that Renee had been visibly drowsy, late to call lights, and unpleasant the day before, but once she knew that Renee had incorrectly taken her husband’s vitals, she immediately threatened to file a formal negligence complaint with the Kansas Insurance Department and the CMS Office of the Regional Administrator in Kansas City, Missouri, if Renee was not fired immediately. Pam returned to her office to discuss the proper course of action with Bruce. She had several considerations and a combination of possible outcomes. First, this occurrence was the first documented complaint against Renee since she had been manager, and Renee had been a very highly regarded nurse for the eight years she had been with PRMC. Since Pam liked to get to know her employees, she also knew that Renee and her husband were struggling financially and had three children to support. Her unconventional schedule had been developed to offset her husband’s work schedule so that one parent could always be home with their children since they could not afford childcare. However, she too had noticed Renee coming to work midrotation looking exhausted and not as cheery as she was on the first few days of her rotation. Next, Pam had to consider the implications of the formal grievance and how it would affect her department and ultimately the hospital. Felix’s increased length of stay would already prevent the hospital from being reimbursed for his care, but Pam had to consider if firing an employee over a single mistake was at all justified to further protect the reputation of the hospital.

Questions

1. How should Pam handle the complaint by the patient? What is the danger of disregarding the patient’s complaint?

2. Should Pam consider changing Renee’s shift schedule? Are there any limits to the amount of shifts or hours that nurses should work? Do you think there should be?

3. How should Pam respond to Felix’s wife’s demand that Renee be fired?

4. Should this situation be addressed by a QI team, or is this simply an unfortunate situation arising from a troubled employee?

5. Could this situation have been avoided if the organization’s human resource management systems had been different? If, so, what HR systems might have played a role in this situation?