2. Discuss some strategies each actor could use to deal with the
preconceptions assumptions and mental models evident in this
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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