Case Study: Right Action, Wrong Result?

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Administrative Summary of Events

An 18-year-old male patient with a history of paracetamol abuse was admitted to the emergency department by his parents. The patient denied consuming excess pills while the parents indicated that they were confident he had consumed overdose levels of paracetamol within the past 6-10 hours. The attending physician chose to forgo a gastric lavage (which requires a response time of 30-60 minutes) and ordered a blood test to determine salicylate levels (Gehle, 2001, pg. 16). The technician conducting the test reported the results to the nurse responding at the register’s desk per physician instructions. Test results indicated negative salicylate level results. Due to a miscommunication, paracetamol results were recorded as “2.13”. The physician consulted a graph to determine if the recorded paracetamol levels were toxic, determined they were below overdose levels, ordered the patient to be held overnight for psychiatric review, and concluded his shift. The patient later presented overdose symptoms in the form of untreatable liver failure, was unable to obtain a timely donor, and ultimately died of chronic liver failure.

Performance Improvement Opportunities

This case study presents a multi-level/multi-departmental failure in due diligence, patient advocacy, and adherence to a defined set of standardized operating procedures. It is recommended that the following set of performance improvement opportunities be addressed:

Paracetamol cases where the patient has a prior history of overdose should be treated as escalated cases, automatically requiring the responding physician to adhere to the overdose protocol checklist; color-coded charts are preferable (Nolan, 2013, pg. 17).

All protocol checklists and graphs must be current, unaltered, and clearly displayed.

Lab results should be communicated directly to the physician or a tenured nurse.

If a tenured nurse/physician is unavailable to receive results, the lab technician must ensure that the respondent understands how to accurately record the results, and request an additional confirmation when a physician or tenured nurse becomes available.

A follow-up exam and additional testing must be conducted within a specified time period while treatment is still available unless the original test is definitively negative.

Expectations, Training, and Accountability

Hospital administration holds the reasonable expectation that separate departments working independently, yet in a collaborative effort to provide patient healthcare, should follow a standardized set of procedures/protocols, specifically when dealing with healthcare issues requiring timely emergency services and the identification of specific non-medical emergency situations. Personnel should advocate for the patient’s welfare by ensuring that all inter-departmental communications are accurate, addressed quickly, and that vital information is discussed in universally understood terminologies (AHRQ, 2013). Accountability, in this case, lies primarily with the physician’s failure to advocate for the patient’s welfare by meeting these expectations but is also shared by the nurse and technician.

Administrations’ response to this particular case is to coordinate collaborative training efforts in order to improve interdepartmental communication and understanding of the separate yet intertwined processes. Furthermore, a safety-net system will be built into the mandated overdose protocol as outlined in the previous section; the protocol checklist will be regularly re-trained, SE MOS audited for accuracy and clarity, and to determine if it was in fact completed by the involved parties (JACHO, 2013, pg. 16). Upon communicating these expectations and completing training objectives, any failure by hospital personnel to adhere to these guidelines and protocols would be punishable by suspension, termination, and possible legal repercussions.


Agency for Healthcare Research & Quality. (2013). Section 3. Measuring emergency department performance. Retrieved from

Gehle K. MD. , Pharagood-Wade F. MD., Johnson D. RN, B., & Rosales-Guevara L. MD., B. (n.d.). Case studies in environmental medicine: Toluene toxicity. Retrieved from website:

Joint Commission of American Hospital Organizations (JACHO). (2013). Sentinel event (SE). Retrieved from

Nolan, L., Regenstein, M., Anthony, D., Siegel, B. (2013). Emergency department operations in top-performing safety-net hospitals. July, 2009. The Common Wealth Fund. Retrieved from