Paralysis from a Medical Error

Patricia W. Iyer, MSN RN LNCC CLNI

Table of Contents  (Back to book ordering page)

Introduction 3
Meet Mr. Kelly 3
Risk Factors for Falls 4
Ten Ss: Factors Associated with Falls 4
Scoring Risk Factors 5
The Fall 6
SBAR 6
Incident Report 8
The Documentation in Mr. Kelly’s Chart 9
Deterioration in Neurological Status 10
Development of a Timeline 14
Key Elements of a Timeline 15
The Patient’s Account of the Night Shift 17
The Clinical Outcome 20
The Clinical Issues 25
Anatomy 25
Diagnosis of Acute Spinal Cord Compression 26
Treatment for Acute Spinal Cord Compression 27
Long-Term Survival 27
Liability Issues: Standard of Care 27
Testimony of June Wether, the Night Shift Nurse 30
National Standards and Facility Standards: Fall Prevention 35
Legal Outcome 36
Lessons Learned 36

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