2. Discuss some strategies each actor could use to deal with the
preconceptions assumptions and mental models evident in this
scenario.
3. What retraining would you recommend for the physicians and
nurses in this scenario?
Case Study in Organizational Behavior
Prelude to a Medical Error
Mrs. Bee was lying in her bed after her morning physical
therapy with Mr. Traction and felt like she couldnt breathe. Is
something bothering you Mrs. Bee? asked Nurse Karing. I know you
had a disagreement with your husband regarding rehabilitation last
night she said. Nurse Karing knew that Mrs. Bee had had a bad fall
and that therapy was going to be tough for her to deal with. She
had discussed with Mrs. Bees husband the support issues that were
important during stressful hospitalizations and it seemed like he
was going to be a good support system for her. She felt that the
disagreement wasnt the real problem.
The previous night Mrs. Bee had terrible spasms in her left
calf and told Nurse Karing right away. Nurse Karing proceeded to
order a STAT venous Doppler X-ray to rule out thrombosis. She also
paged Dr. Cural to notify him that Mrs. Bee was having symptoms of
thrombosis. Dr. Cural upset that he was being bothered after a long
day of work shouted into the phone I evaluated that patient this
morning and nothing was wrong with her. I dont need incompetent
nurses calling me at night to tell me that my patient is having leg
cramps. Dont bother me again! And by the way cancel that test!
[Click.] Nurse Karing was upset. She felt humiliated and
distracted. She canceled the venous Doppler test as ordered by Dr.
Cural thinking he was right. Mrs. Bee was probably just having leg
cramps from being sedentary that day. And besides she thought Dr.
Cural had always claimed to know his patients inside and out. Yet
Nurse Karing went home that night feeling bothered by the lack of
respect and communication displayed by her coworkers lately.
But today Mrs. Bee was short of breath pale and had elevated
blood pressure. Something was wrong. Nurse Karing ordered a STAT VQ
scan to rule out a pulmonary embolus. This was serious. Mrs. Bee
was starting to go unconscious. Nurse Karing immediately called for
help. The nursing team and Dr. Krisis (from the ER) came
immediately to the room to help stabilize Mrs. Bee. Looks like we
have another problem from one of the nursing floors observed Dr.
Krisis. Someone must have not had time again to call the doctor
yesterday to see if a venous Doppler was necessary. Now shes really
critical! Nurse Karing ignored Dr. Krisiss comment and quickly
collected Mrs. Bees chart to notify Dr. Cural of the situation. Dr.
Cural was angry. Why didnt anybody call me to tell me that my
patient was having problems? I am the physician! Cant you nurses do
anything right? Dont you know that you need to focus on what
symptoms Mrs. Bee is having? Get Mrs. Specimen up here to draw some
blood. I want STAT ABGs now! Get ICU on the phone!
At the same time Mr. Friendly the social worker happened to
be walking by and said to Dr. Cural and Nurse Karing Mrs. Bees
paperwork is all ready. Her insurance will allow her to go to a
rehabilitation facility for one week of physical therapy. The
MediCar will be here in one hour to pick her up. Nurse Karing was
furious. She thought to herself Its time for administration to hear
this one.
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