practice partner
Patient Safety
We use this forum to regularly report on findings from patient safety organizations, expert review
committees of the Office of the Chief Coroner, and inquests.
High index
of suspicion
for fracture
in frail elderly
warranted
Continued on pg. 52...
50
Dialogue Issue 2, 2015
photo: istockphoto.com/shapecharge
H
and respiratory difficulties. She was found to be in respiealth-care professionals are reminded to
ratory failure and required intubation and ventilation.
have a high index of suspicion of fracture
She was subsequently extubated but was diagnosed with
or significant injury in frail, immobile
pneumonia. She died in hospital on March 30, 2011.
seniors even in the absence of known
Early in March, it was recognized that she had intrauma and definitive clinical signs of trauma, reminds a
creased problems with swallowing and the diet texture
Committee of the Chief Coroner’s Office.
was changed. There were problems with
The reminder is made by the Geriatric
positioning of the neck. Hyperextenand Long-Term Care Review Commitsion was thought to be interfering with
tee after reviewing the case of a 75-year“Long-term care
swallowing. The committee suspects that
old woman who died in a long-term care
documentation tools she developed aspiration pneumonia as
facility.
The woman had been confined to a
should allow staff a result of her dysphagia. It is difficult to
wheelchair as a result of a hemiparesis
to identify trends in definitively link her death from pneumonia to a minimally traumatic fracture that
from two previous strokes and osteopain, behaviour or possibly occurred three months earlier.
arthritis. She was legally blind due to
The MOHLTC carried out an inspecdiabetic retinopathy and glaucoma. She
medical care”
tion as a result of this critical incident.
required a mechanical lift for transfers.
Orders and written notices were directed
She had previous complaints of knee
to the facility. A risk management review was carried
pain. On or around December 19, 2010, she probably
out and a corrective action plan was put in place.
sustained a tibial plateau fracture that was not conIn the risk management review conducted by the
firmed by X-ray until January 13, 2011. She was treated
long-term care home, staff members were extensively
conservatively with splinting and analgesia.
interviewed. They did not appear to recognize a
On March 10, 2011, she had fever and was treated for
significant change in the patient’s behaviour or status
a urinary tract infection. The patient was again transas she had a long-standing complaint of knee pain.
ferred to hospital a week later because of a febrile illness