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Ruby’s story: The errors prevailed

Updated: Nov 15, 2019

"Safety: It takes all of us." According to the National Patient Safety Foundation, there are a number of ongoing patient safety challenges, including medication errors, falls, readmissions, and diagnostic errors. Access to medical records, the education needed to understand them—for both patient and clinician—and coordinated care are all ways to address these patient safety challenges.


Here's a personal story of how access, education, and collaboration (or, more precisely, the lack of these) affected the safety of a patient, Ruby.



Ruby’s story begins

After falling down a flight of stairs, Ruby, who is in her 80s, was banged up and had soreness in her knees and left foot. She was taken by ambulance to her local hospital where her son Brent joined her. Once admitted, she underwent a physical exam and X-rays. So far, so good…


First error, harm avoided: Not recognizing falling risk

After Ruby arrived at the hospital, the radiology report showed a small break in her foot, so she was given a temporary cast in anticipation of an orthopedic review. After that, the plan was a meeting with the orthopedist and discharge to a skilled nursing facility for rehab. All sounds good. However…


“...this is an instance where not speaking up could have resulted in another tumble and further complications.”

During the course of the initial emergency department observation, Ruby asked to use the restroom. The nurse assistant offered to help Ruby get up to walk to the bathroom. It took a family member pointing out that this situation—a woman in her 80s who just had a boot put on her foot, trying to navigate past the cast cart to the bathroom—might be better served by using a bedpan. The assistant paused and went with the bedpan idea. It may go without saying, but this is an instance where not speaking up could have resulted in another tumble and further complications.


Second error, harm avoided: Not knowing about medications

Ruby wisely brought her complex list of medications and advance care documents along with her to the hospital. Initially, the nurse didn’t enter the drugs into the patient chart. And when she did, she had only attached the scanned documents in the record notes. Generally speaking, pharmacists and the attending physician don’t read scans of medication lists placed in the nursing notes. They only take notice when the medications are entered into the proper section of the medical record.


After prodding, the nurse properly entered the information, but she wasn’t happy about having to do it.


What can we take away from this? While clinicians do a great job, they are human. They have bad days. We need to be advocates for ourselves and for our loved ones when it comes to patient safety.


Third error, harm NOT avoided: Misdiagnosis and readmission

So there Ruby sat in the skilled nursing facility, still with her temporary cast. But she did not improve. In fact, she fell again. Her son Brent questioned the facility about the recommendations of the orthopedist and asked why his mother still had a temporary cast.

The truth? The orthopedist never saw her. She had been discharged without review.

How did Brent know? After not getting any answers, it was clear that there were no known instructions from the hospital for the skilled nursing facility staff. So Brent asked to review Ruby’s records. Luckily, he knows the law, but not everyone does. As the person with medical and durable power of attorney for his mother, he was given a copy of her records.

"...but the temporary cast had been placed on the wrong foot! “I didn’t know a bunch of the words in the radiology report,' he said, 'but I do know right and left.'"

After Brent reviewed the records, he discovered that not only had his mother not been seen by an orthopedist, but the temporary cast had been placed on the wrong foot! “I didn’t know a bunch of the words in the radiology report,” he said, “but I do know right and left.” Ruby was sent back to the hospital in an ambulance. A new X-ray was ordered, and it was discovered that neither foot was broken.


This may sound like good news, but Ruby’s medical ordeal was not yet over.


Unnecessary procedure: Cardiac catheterization

When Ruby arrived for the second time to the ER, the physician was concerned about her elevated enzymes. She had a history of a parasite that had damaged her kidneys and liver. Although she had no other symptoms of heart attack or stroke, she was given a cardiac catheterization and placed in the intensive care unit.


She was discharged to the skilled nursing facility 2 days later, luckily with no complications or infection, but this continued inactivity made her health deteriorate even faster.


Errors with harm: The bad news

Precious time was lost due to medical errors related to access, education, and coordinated care, and Ruby’s inactivity created weakness and loss of muscle tone. All of this resulted in Ruby never going home again. She now lives in an assisted living facility.


The solution? Shared decision making and a coordinated care approach

In an ideal world, shared decision making would have guided the conversations between Ruby and her care team from the very beginning. It would have caught the lack of clinician involvement. A coordinated care approach would also have caught errors that ultimately put Ruby in an assisted living facility.

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