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Grace’s  Story   Grace  Smith  was  a  50  year  old  successful  business  woman  for  an  international  fashion

  design  company  located  in  New  York  City.    She  travels  internationally  at  least  twice  a  month   mostly  to  Paris  and  London.    A  recent  change  in  the  company’s  Board  of  Directors  had   created  an  increased  work  load  and  she  had  gained  about  30lbs.    She  had  hoped  her  new   exercise  routine  including  jogging  at  4am  before  work  would  help  combat  the  increased   stress  and  weight  gain.   One  morning,  frustrated  by  a  text  message  that  her  flight  would  be  delayed,  she  fell  on  the   jogging  path,  hit  her  head  and  severely  broke  her  leg.    Upon  arrival,  she  was  in  so  much  pain   and  was  so  upset  at  the  site  of  the  bone  sticking  out  of  her  leg;  she  demanded  to  be   transferred  to  Hope  Hospital  immediately.    Despite  repeated  questions  from  the  emergency   medical  technicians,  she  was  focused  on  calling  her  assistant  to  inform  her  of  what  had   happened  and  did  not  report  that  she  had  hit  her  head.   At  the  hospital,  the  emergency  nurse  did  the  best  she  could  to  get  a  medical  history  on   Grace.    Grace  offered  that  she  was  excellent  health  and  that  she  had  never  even  been  in  the   hospital  before.    Grace  reported  that  the  only  medications  she  took  was  vitamins  and   recently  started  hormone  replacement  therapy.    Grace’s  administrative  assistant  walked  in   and  asked  the  nurse  to  step-­‐out  of  the  room  for  a  minute  causing  the  nurse  to  stop   completing  the  history  including  writing  down  the  hormone  replacement  therapy  and   vitamins.  The  nurse  was  informed  that  Grace  sat  on  the  Board  of  Trustees  of  the  hospital.     The  ER  nurse  was  too  nervous  to  go  back  in  and  ask  Grace  any  more  questions.   While  the  nurse  was  talking  to  Grace’s  assistant,  Rob  Hendricks,  the  orthopedic  surgeon  on   call,  went  in  to  exam  Grace.    This  was  his  first  year  at  Hope  Hospital  after  completing  his   residency  at  a  much  smaller  hospital.    He  had  been  just  been  in  the  OR  for  the  past  8  hours.     He  had  been  up  for  26  hours  and  recalled  thinking  about  stories  he  had  heard  in  the   physician’s  lounge  of  senior  surgeons  who  bragged  about  working  36  hours  straight.     Despite  his  best  efforts,  Grace’s  brevity  and  distraction  with  work  calls  and  emails  caused   brief  one  word  answers.    When  he  asked  Grace  about  her  family  history  she  quickly  told  him   everyone  was  “alive  and  well.”    Grace  forgot  to  mention  that  her  brother  who  was  only  42   years  old  had  recently  had  a  recent  heart  attack  although  he  had  a  similar  high-­‐stress  job.   Rob  reviewed  Grace’s  x-­‐ray  and  informed  the  OR  to  prepare  her  for  surgery.    Given  her   history,  Rob  considered  her  bleeding  risks.    Although  the  hospital  where  he  did  his   residency  had  a  Venous  Thromboembolism  (VTE)  Risk  Assessment  and  protocol,  Hope   Hospital  did  not  and  each  physician  usually  wrote  individual  orders  dismissing  Hope   Hospital’s  protocol  as  too  complicated  for  the  nursing  staff  to  follow.     Rob  performed  the  surgery  without  incident.    Grace  was  admitted  to  post-­‐operative   orthopedic  floor.  

”         Grace  did  well  and  worked  on  her  laptop  most  of  the  following  couple  of  days.  four  children  and  a  newborn  grandchild.  she  just  told  her  she   needed  pain  medication  for  leg  cramps.Amy.    Although  the  nurse  was  informed  that  Grace  had  called.  she  walked  away….    She  was  survived  by  her   husband.    She  had  had  several  bad   interactions  with  Rob  since  he  arrived.     .  she  was  in  the   middle  of  working  with  another  patient  and  did  not  get  into  Grace’s  room  immediately.    On  the  third   night.  reviewed  her  orders  and  was  surprised  to   find  no  VTE  prophylaxis  ordered.”I’m   just  the  nurse.       Grace  died  of  a  pulmonary  embolism  at  5am  that  morning.    Around  4am  she  woke  up  short  of  breath  and  put   her  call  light  on.  she  experienced  leg  cramps  but  when  she  called  the  nurse.  the  nurse  admitting  Grace  from  the  PACU.    When  she  got  no  response  from  Rob.    “So   nothing  for  VTE?”  she  asked.    At  first  she  thought  he  just  needed  to  get  to  know   and  trust  her  but  despite  her  repeated  efforts  he  continued  to  be  condescending.    Amy  had  worked  on  the  orthopedic  unit  for  12  years  and   pretty  much  knew  each  surgeon’s  VTE  orders  by  heart.