A constant turnover of nursing staff. Fragmented medical records. Outdated hospital technology, from DOS, to faxes to pagers. Rushed discharges to free up hospital beds.

And an aging populations with chronic diseases, taking multiple medications and sometimes unable to articulate their needs.

These risk factors all add up. And the longer elderly people stay in hospital, the greater their chance of experiencing errors.

A study in 2015 found that nursing staff were not only unaware of the importance of fluid balance but were also conducting unnecessary monitoring...


A slight woman in her eighties called Daphne was admitted to hospital after experiencing a stroke.

After spending several weeks of treatment, the doctors declared she was stable and safe for discharge to rehabilitation.

Rehabilitation units often required that hospital patients have 'textbook' observations before they are accepted.

However few elderly people with chronic conditions, on multiple medications have the same blood pressure and pulse as a fit young adult.

So pressure is applied to ward staff to 'fit' patients vital signs into narrow limits pre defined by rehabilitation units, most of which are privately run and have few Doctors or Registered Nurses on staff.


Daphne was keen to get out of the noisy, impersonal hospital and into a quiet environment. However, her blood pressure was consistently on the low side.

One of the senior nurses asked a junior doctor to write up intravenous fluids, to quickly raise Daphne’s blood pressure up to 120/70.

However, Daphne’s blood pressure remained borderline. More fluids were ordered. She was also told to drink plenty of water.

Despite this effort, Daphne’s blood pressure remained low. The rehabilitation team insisted that should couldn’t be accepted to rehab. So hospital staff continued to push fluids. Blood pressures were done every four hours.

However, no blood tests were done to check Daphne’s fluid and electrolyte levels.

After three days of continuous fluids both IV and oral, a nurse found Daphne in her room having seizures.

A Code Blue was called, and the emergency team rushed in. Blood tests were quickly done.

They revealed that Daphne's sodium levels were very low. Low sodium levels can increase the risk of seizures. On review, the doctors diagnosed the cause of her low sodium as being related to excess fluids.

"Near misses are the huge iceberg below the surface where all the future errors are occurring...But we don't know where they are ... so we don't know where to send our resources to fix them or make it less likely to happen."

Too many petty rules, not enough common sense

Daphne was immediately put on a fluid restriction of 500 mls a day.

All her intravenous fluids were ceased.

Her rehabilitation bed was cancelled.

Daphne spend yet another week in a noisy, impersonal, error prone hospital.

And patients who needed her hospital bed were turned away.


References

Improving Fluid Balance Charts (and Hypervolaemia v Hypovolaemia) - AusMed May 2020

A Doctor Confronts Medical Errors — And Flaws In The System That Create Mistakes - NPA June 2020

© Wikihospitals 2015