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CASE STUDY

This case study examines the unfortunate fall of a 55-year-old male patient who was admitted for a routine procedure. Despite initially progressing well post-thoracotomy, the patient exhibited increased agitation and aggressive behavior on Day 3, leading to a tragic incident where he fell from a third-floor window. This analysis explores the contributing factors, including his history of alcohol use and the responses from medical staff. Recommendations for improving patient safety, recognizing behavioral risks, and managing alcohol withdrawal are discussed to prevent future occurrences.

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CASE STUDY

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Presentation Transcript

  1. CASE STUDY Dr Byth

  2. An Inpatient Fall • 55 yr male • Routine Booked Admission • Attended HEAPS clinic • ETOH 6 beers / day • Smoker 20/day • Thoracotomy • Post op epidural - good pain relief • ICC slight air leak • Progressed well till…….

  3. Day 3 Post Op • Morning • Mobile • Showered self • Compliant • Late Afternoon / Evening • Restless agitated • Pulling out lines • Packed his suitcase ready to leave • Threatening staff / aggressive

  4. Pre Fall • 18:15 AMO and Pain team contacted • 19:00 Admits regular ETOH intake • 19:45 Reviewed by RMO • Admits 60-70 grams daily 15+years • PRN diazepam charted ETOH score 1 nil – nil administered based on score • Patient compliant • 20:20 Increased agitation……the fall……

  5. 20:20 pm • Pt increasingly agitated • Three nurses present • Other patients in room leave • Nurse leaves room to call security / RMO • Requested assistance immediately • Patient punches out screen & climbs on sill • Attempts made to coax pt back

  6. The Fall • Patient Fell from 3rd floor window • Arrest team call • Poor lighting resulting in difficulty in finding pt • Patient deceased

  7. Internal Processes • Report Type – System Analysis RCA • Reported to Clinical Governance Unit • Internal Process – RCA

  8. Actions • Ward safety • Review design of windows • Location of duress buttons • Preoperative identification of Risk • Recognition of risk of ETOH withdrawal

  9. Actions……continued • Management of Acute Delirium • Education and training of ETOH withdrawal • Use of benzodiazepines in ETOH withdrawal • Documentation • Reinforce importance of documentation of time when entering into patient notes • Ensure all documentation on admission is reviewed

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