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Links
to Other System Healthcare International Sites:
Manama
Bahrain
Tripoli
Libya
(Pre-Development)
Brunei
Borneo Island (PD)
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Contact
us:
email: info@jhardy.com
USA Telephone:
(800) 233-5313
USA Mobile:
(415) 531-0295
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Port Harcourt
Nigeria
-
Jeff Hardy -
Creator of the
NO Hidden Patient Hospital Design for Maximum
Patient Safety
See "NO Hidden Patient" Articles
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Reports from state
Departments of Health Services (DHS)
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DHS Reports:
Our objective is not to blame. Our goal is do what's right. Although
the following reports from several
different "Department of Health Services " (DHS)
from several different states are documents of public record,
this site is specifically focused on presenting examples of how
the physical layout of a hospital, clinical care unit or other units,
contribute to the death, harm or poor patient care. We are specifically
NOT interested in assigning blame to any one hospital because our
goal is to use these examples when both planning
and performing failure avoidance during the new hospital
design process. "NO Hidden Patient" is not an easy or
inexpensive policy to implement.
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| DHS
Reports |
DHS
Report: "On interview a licensed staff stated that patient
"X" fell out of bed when left unattended with a section of the bed
rails in a lowered position. Patient "X" sustained a head injury necessitating
admission to the Intensive Care Unit. Even though the nursing assessment history
and physician admission reflected previous falls requiring surgical intervention,
this information was not used to develop a plan of correction. The plan of correction
developed by the facility did not include fall preventative measures to include
goals, problem needs and approaches for therapeutic staff intervention."
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DHS
Report: "Patient left the room without assistance [and was discovered
by a hospital security officer at a bus stop at the entrance of the ED parking
lot.]" |
DHS
Report: Nurse "X" stated that at lunch time he/she noticed
that patient "Y" was in bed in a slumped position with the food tray
over the bed. The nurse suggested the patient sit in a chair for lunch, assisted
the patient out of bed and stated that he/she sat well in the chair and ate his/her
entire lunch…Nurse "X" then went to lunch and checked on patient
"Y" upon return, the patient was back in bed with the spouse in the
room. The nurse did not know if anyone had assisted the patient back to bed…
Nurse "X" documented in the medical record, "patient got out of
bed trying to go to bathroom then fell (after)slipping on…own urine…
found patient lying on… back, bleeding from back of head, pressure applied…"…The
physician ordered a CT scan of the head which showed that the patient had a subdural
hematoma (bleeding in the brain)…[After a rapid decline] the patient expired." |
DHS Report:
Elderly Pt admitted through ER after a fall. Advanced carcinoma. Comfort care
ordered. Pt died unattended without family notification as required. Pt was cool
when family member found, indicating hours had passed since last nursing check.
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DHS
Report: 94-year old woman with history of falls admitted thru ER for
weakness. The plan of care failed to document her history or status on admission.
Bed rails were up, she had previously climbed out of bed but no restraints used.
She fell out of bed and broke her hip within 24 hours of admission. |
The
'DHS Reports' page is constantly being updated
Most recent update:
Keep checking back for more perspiration and inspiration!
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