Day of Occurrence

POINT OF CARE: OUTPATIENT (DIALYSIS CENTER)

MEMBER OF TEAM: Dialysis technician

Nephrologist: Jesse, Nurse Mercedes
DAY 1 (MONDAY)

POINT OF CARE: OUTPATIENT (HOSPITAL)

MEMBER OF TEAM: Hospital clerk (Jonas)

Day 2 (TUESDAY)

POINT OF CARE: OUTPATIENT (DIALYSIS CENTER),

Emergency Dept

MEMBER OF TEAM: Emergency Dept Care Team

Day 3 (WEDNESDAY)

POINT OF CARE: INPATIENT (HOSPITAL)

MEMBER OF TEAM: Nurse (Lydia), Social Worker:
Ana

Day 7 (SUNDAY)

POINT OF CARE: OUTPATIENT (HOSPITAL)

MEMBER OF TEAM: Nutritionist

Day 8 (MONDAY)
 Day 8 (MONDAY)

POINT OF CARE: OUTPATIENT (DIALYSIS CENTER)

MEMBER OF TEAM: MEDICAL ASSISTANT

DAY 9-24

POINT OF CARE: INPATIENT (Emergency Dept),

General Medicine Unit
MEMBER OF TEAM: Emergency Dept, Social
Worker, Nutritionist
DAY 25 (THURSDAY)

POINT OF CARE: INPATIENT General Medicine Unit

MEMBER OF TEAM: Emergency Dept Care Team

DAY 36 (MONDAY)

POINT OF CARE: OUTPATIENT (DIALYSIS CLINIC)

MEMBER OF TEAM: Dialysis Nurse (Mercedes), Socia

DAY 38 (WEDNESDAY)

POINT OF CARE: INPATIENT (Emergency Dept),

General Medicine Unit, Medical Surgical Unit
MEMBER OF TEAM: ED Nurse, ED Physician

Day 39 (THURSDAY)

POINT OF CARE: INPATIENT MED SURG Unit, ICU,

Long term care facility

DAY 40 (FRIDAY)
 POINT OF CARE: INPATIENT MED SURG Unit, ICU,
Long term care facility
MEMBER OF TEAM: Medical student (Grant),
Attending Physician (Valerie), neurosurgeon
DAY 40 (FRIDAY)

POINT OF CARE: (INPATIENT) Long Term Care Facility

MEMBER OF TEAM: Social Worker

DAY 41 +

References:
Baum, K. (2017, June 8). Case studies: IHI - Institute for healthcare improvement. Instit
http://www.ihi.org/education/IHIOpenSchool/resources/Pages/CaseStudies/default.as
IHS CASE STUDY I: CARLA'S STORY OF CARE

Carla has poor circulation through her

hemodialysis catheter. An ultrasound has been
scheduled for the next morning at a hospital 8
hours away. Carla is too embarrassed to tell the
nurse that she no longer has a car and have to
take the bus.

Carla is 30 minutes late to her appointment due

to taking 3 buses to get to the hospital. Carla is
unable to be seen and must reschedule for
Thursday at 10am.

Carla has a fistula that was noticed during her

dialysis treatment. Carla also has elevated
potassium levels and has to be sent to the
emergency department for proper treament. Her
shunt has also been replaced and potassium
corrrected.

Carla is discharged and feels overwhelmed with

the dialysis process. She is assigned a social
worker and has an appointment with a
nutritionist for diet management.

The hospital made an appointment for Carla with

a nutritionist without being able to confirm with
Carla. Carla missed her appointment.
Carla notified the medical asssitant at the dialysis center
that her INR should be checked daily. The MA was not
notified by his authorities of these changes. Carla has
been consuming large amounts of spinach in attempts
to be healthy. She was unaware of the high levels of
potassium in spinach which counteracts with the
current medication (warfarin).

Carla presents to the emergency department due to

right arm pain in which a DVT was discovered. Carla was
treated. Carla's social worker contacts the dialysis
center to ensure that Carla's INR is checked daily. Carla
meets with a nutritionist to discuss proper food options.

Carla is discharged from the hospital. While

home she feels nauseous.

Carla decides to skip dialysis. Carla's face begins

to tingle. She feels exhausted and decides to
sleep.

Carla's tingling sensation got worse and she was

taken to the ER. After waiting 2 hours to be seen,
the neurologist only does a cursory exam. Her
potassiium levels came back high and she was
admitted and sent for dialysis. Carla still has the
same symptoms and was given medications.

Carla's fatigue was noticed by a medical student

and the attending was notified. An emergency ct
scan was ordered. Carla was diagnosed with
having a subdural hematoma. The hematoma
 Carla's fatigue was noticed by a medical student
and the attending was notified. An emergency ct
scan was ordered. Carla was diagnosed with
having a subdural hematoma. The hematoma
was removed and Carla was givien medication.

Carla has suffered a short term defecits after the

surgery. She can no longer care for herself. At the
age of 30, she is the youngest resident at the
long term care facility.

care improvement. Institute for Healthcare Improvement: Open School.

es/CaseStudies/default.aspx.
ORY OF CARE