Reference no: EM133281956

Assignment:

Read the following and answer the following:

A speech language therapist (SLT) holding a language group with 5 clients in the day rehab outpatient setting of a hospital noticed an elderly patient with a history of mental illness and post stroke (CVA) left the SLT group session early. The SLP asked the client, Kathleen, who is usually very social and chatty, why she was leaving the group early, Kathleen responded several times that she just did not feel well. The patient had a history of major depression, reported frequent physical ailments, and lived in a psychiatric community group home. The SLP notified the nurse overseeing Kathleen's care that day. The nurse arranged for transportation services to take her to the hospital's urgent care center for further evaluation given her history. There was a significant delay in transporting Kathleen.

Finally, when the transport escort transported Kathleen to the urgent care department, she was instructed to sit in the transport wheelchair until she was called for her evaluation. Although health care professionals were nearby, there were all very busy and never approached the patient. When the SLP finished her language group session, she walked over to the urgent care department to see how Kathleen was. The SLP saw Kathleen in the waiting room and approached her, it was apparent to the SLP she was not breathing. The SLP quickly went to the department intake desk and asked a nurse to confirm her findings. Indeed, she had no pulse and no respirations. CPR was initiated and the code team notified and responded. Unfortunately, the patient succumbed to her cardiac arrest and died.

1. Based upon the actions taken in this case do you believe there was an error in professional judgement and or communication by the healthcare professionals?

2. Can you identify why the healthcare professionals might have assumed that their actions were professionally acceptable given the situation?

3. Do you believe that the healthcare professional's actions were in error?

4. What do you think the team members could have done to address the situation presented in the case so as not to compromise patient safety?