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Original Question

Mr. Johnny Jones, an eighty-five-year-old male presented to the emergency department (ED) with a closed-head injury from a fall. He was transferred via ambulance from an assisted living facility. He has one daughter that lives out of state. Mr. Jones was alert and oriented to person, place, and time but still a poor historian. His family was not available during the intake process. However, he did disclose to the nurse he takes medicine for blood pressure and maybe something else. Mr. Jones also communicated to the ED nurse his primary care doctor told him to cut back on salty foods. He told the ED nurse he is not able to get around like he used to, so that is why he lives in an assisted living facility. Mr. Jones was headed to the dining room for lunch when his right knee “gave away” which led to his fall. When the ED nurse asked Mr. Jones for his daughter’s contact information, he was not able to recall his daughter’s number. The nurse proceeded to reconcile his medications. Mr. Jones stated he takes two blood pressure pills, a baby aspirin, and a new medicine that the doctor gave him two months ago. He described the new medicine as a “tiny white pill.” After becoming frustrated, Mr. Jones told the nurse, “I was just here a few months ago when I had my heart attack, you should have my records.” He also inquired, “Aren’t my records in the clouds”? Based on the Mr. Jones’s interview, the health team concluded he had a medical history of hypertension, past myocardial infarction, and arthritis. A medication list based on Mr. Jones’s past ED visit: • HCTZ 25 mg by mouth twice daily • Atenolol 50 mg by mouth daily • ASA 81 mg by mouth daily • Aleve by mouth as needed for pain • Nitro SL 0.4 mg as needed for chest pain/ 1 tablet every 5 minutes as needed up to 3 times Based on assessments performed by the ED doctor and nurse, it was determined Mr. Jones had no neurological deficits. A BMP and CBC were ordered. The results were normal. Mr. Jones was discharged home with instructions to rest, continue his current medications, and follow up with his primary care physician in the morning. His discharge diagnosis was a right-sided hematoma to the scalp region. Mr. Jones was discharged back to the assisted living facility. During the night, Mr. Jones became unresponsive. He was rushed back to the ED via ambulance in a comatose state. More diagnostics were ordered and completed. The results revealed Mr. Jones had a subdural hematoma, a toxic digoxin level, and an INR of 9. After finally speaking with the patient’s daughter, the health care team learned Mr. Jones is on digoxin 0.5mg by mouth daily for treatment of atrial fibrillation. Also, he had been started on a Coumadin dose of 3 mg by mouth daily. The ED attending physician was very upset. The physician stated, “If this information had been disclosed during his last ED visit on yesterday, I would have ordered an EKG, dig level, PT/INR, and a CT scan without contrast. Include all of the following concepts when answering the discussion questions below: • Informatics • EHR • Quality Improvement • Communication • Safety • Interdisciplinary team 1) What were some of the major contributors to Mr. Jones’s misdiagnosis? 2) What were some of the safety concerns related to Mr. Jones’s care? 3) How pertinent was the omitted information to Mr. Jones’s plan of care and his clinical outcomes? How can the omitted information be integrated into an electronic health record (EHR)? Which meaningful use metrics should be considered? 4) Describe how an IP, approach along with the implementation of the EHR, could have improved Mr. Jones’s care resulting in a more favorable outcome and prevent similar issues from occurring. 5) In regards to the electronic health record, what are 3 recommendations to improve the quality of care provided in the ED?

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