Case scenario:

Debriefing Exercise

Graham is an 84-
year-old man with
hypertension and
rheumatoid arthritis.
Graham is a patient at
North Star Living nursing home. Graham has a history of frequent falls
related to his chronic pain and episode of orthostatic hypotension on
transfers. In his care plan the nurse along with the physio therapy
have implemented interventions to prevent Graham’s falls. Graham’s
family lives out of town and are not able to visit him often as they
would like to. Therefore they trust the care of their dad in the hands of
the health care team at the nursing home. You are a recent graduate
from Centennial College and you have gained great experience in the
skills lab and theory class. You are assigned Graham as your patient;
Graham rang the call bell for assistance and asked to be transfered to
the commode to have a bowel movement. The nurse had just given
Graham his Percocet for his arthritic pain. As the PSW you are aware
that one of the side effects of Percocet is lightheadedness, dizziness
and drowsiness.
You received report from your peer; the report stated that Graham is
 Alert and oriented
 High risk for falls, keep call bell within reach, bed in lowest
position
 Generalized weakness
  Chronic arthritis pain takes Percocet for pain (PRN) Medication
was given 15 minutes ago.
 Transfer to commode to be toileted
 Requires 2 person for transfers
 Occasionally gets dizzy on transfers due to orthostatic
hypotension
 Set up for meals
 Stage 1 coccyx ulcer
 Reposition q2hrs, pillows at pressure points.
You performed hand hygiene; knock on the door before entering. You
introduce yourself and indentified your patient. You explained what
you were about to do and how long it will take. You’ve called for a
peer to assist; however they’re currently busy with another patient.
Graham is getting anxious because he has a strong urge to have a
bowel movement. Considering all the obstacles, you decided to
transfer Graham independently because there isn’t anyone available
at the time to assist and you assume that should be quite easy since
he has a small frame. On transferring Graham to the commode,
Graham becomes significantly dizzy, you lose your balance and
Graham falls to the floor, hitting his head against the corner of the side
table.
Question
1) Has a medication-related safety incident occurred?
Yes, The medication for pain Percocet® or Oxycodone can cause
drowsiness, that is a feeling of being sleepy and lethargic, being linked
to a increased the chance of fall. Considering this adverse effect we
can assume that it was a medication-related safety incident.
2) What went well in this scenario?
All procedures to maintain client privacy and safety (hand hygiene,
knocking on the door, introduction, explanation of procedure to
patient, calling for assistance) were followed until student decided to
transfer Graham alone.

3) How can the health care team could have

collaborated/communicated to improve this situation?

Considering that all other health providers (psw, nurses) where busy,
not being available to help with Graham transfer. We should assume
that staff were limited. Still they should be provided information about
stool procedures when client can not be transferred