I had a reasonably healthy, very elderly lady yesterday. New onset CHF, day 2 of admission. Diuresing perfectly, not a single complaint except uncomfortable foley (found an overinflated balloon when removing it). No crackles, was walkie/talkie, EF 50-55, some regurg in a couple of valves (m&t I think?), elevated PAP (40s) (that echo was yesterday).
Did sundown at night. A&O during the day, though. No s&s of bleeding, no abnormal labs except BNP, which was not all that impressive. Just high enough to get the diagnosis and a room. Her whole reason for coming in was some shortness of breath that didn't want to go away for 2 weeks.
So today, she suddenly died. I didn't have her today, but her nurse says she was sleepy in the morning, seemed totally okay, suddenly decompensated, and coded. No clue what happened.
My understanding of root cause analyses is that they're turned to when there is a surprise like this one. With her being nearly 100, perhaps it won't go that direction? Are RCAs only initiated and done in house? Or do outside people get involved? If one is initiated, is this an instance where I should get in touch with NSO (my malpractice insurance carrier)?
The nurse who had her actually switched shifts with me. He was supposed to have her yesterday, and I was supposed to have her today. Poor kid..... He's so fresh out of school. I'm sure this has messed with his head a bit.
A must read article on Root Cause Analysis... (added by staff May 2018)
