Discussion: Case Study - Prelude to a Medical Error

Read the case study below and response to these questions:

1. Identify and discuss examples of preconceptions, assumptions, and mental models evident in this scenario. What are the consequences of the ways these health providers are thinking about the situation?

2. Discuss some strategies each actor could use to deal with the preconceptions, assumptions, and mental models evident in this scenario.

3. What retraining would you recommend for the physicians and nurses in this scenario?

Case Study in Organizational Behavior

Prelude to a Medical Error

Mrs. Bee was lying in her bed after her morning physical therapy with Mr. Traction and felt like she couldn't breathe. "Is something bothering you, Mrs. Bee?" asked Nurse Karing. "I know you had a disagreement with your husband regarding rehabilitation last night," she said. Nurse Karing knew that Mrs. Bee had had a bad fall and that therapy was going to be tough for her to deal with. She had discussed with Mrs. Bee's husband the support issues that were important during stressful hospitalizations, and it seemed like he was going to be a good support system for her. She felt that the disagreement wasn't the real problem.

The previous night, Mrs. Bee had terrible spasms in her left calf and told Nurse Karing right away. Nurse Karing proceeded to order a STAT venous Doppler X-ray to rule out thrombosis. She also paged Dr. Cural to notify him that Mrs. Bee was having symptoms of thrombosis. Dr. Cural, upset that he was being bothered after a long day of work, shouted into the phone, "I evaluated that patient this morning, and nothing was wrong with her. I don't need incompetent nurses calling me at night to tell me that my patient is having leg cramps. Don't bother me again! And by the way, cancel that test!" [Click.] Nurse Karing was upset. She felt humiliated and distracted. She canceled the venous Doppler test as ordered by Dr. Cural, thinking he was right. Mrs. Bee was probably just having leg cramps from being sedentary that day. And besides, she thought, Dr. Cural had always claimed to know his patients inside and out. Yet Nurse Karing went home that night feeling bothered by the lack of respect and communication displayed by her coworkers lately.

But today, Mrs. Bee was short of breath, pale, and had elevated blood pressure. Something was wrong. Nurse Karing ordered a STAT VQ scan to rule out a pulmonary embolus. This was serious. Mrs. Bee was starting to go unconscious. Nurse Karing immediately called for help. The nursing team and Dr. Krisis (from the ER) came immediately to the room to help stabilize Mrs. Bee. "Looks like we have another problem from one of the nursing floors," observed Dr. Krisis. "Someone must have not had time again to call the doctor yesterday to see if a venous Doppler was necessary. Now she's really critical!" Nurse Karing ignored Dr. Krisis's comment and quickly collected Mrs. Bee's chart to notify Dr. Cural of the situation. Dr. Cural was angry. "Why didn't anybody call me to tell me that my patient was having problems? I am the physician! Can't you nurses do anything right? Don't you know that you need to focus on what symptoms Mrs. Bee is having? Get Mrs. Specimen up here to draw some blood. I want STAT ABGs now! Get ICU on the phone!"

At the same time, Mr. Friendly, the social worker, happened to be walking by and said to Dr. Cural and Nurse Karing, "Mrs. Bee's paperwork is all ready. Her insurance will allow her to go to a rehabilitation facility for one week of physical therapy. The MediCar will be here in one hour to pick her up." Nurse Karing was furious. She thought to herself, "It's time for administration to hear this one."

Buchbinder, S., & Shanks, N., Introduction to Health Care Management, 2nd ed. Jones & Bartlett Learning, Burlington, MA. 2012.