TABLE 2

Provider Comments Illustrating Potential Preventability in the Categories of Disease Progression, Previous Admission Complication, and New Disease Process

CategoryEtiologiesComment
Disease progressionDischarge instructions (adherence, understanding)• Did not leave with migraine-specific treatment plan or did not understand plan if given.
• Lack of understanding of asthma treatment at home based on history on readmission that MOC gave flovent but not albuterol when symptoms worsened.
• Yes, if patient did his outpatient lung clearance and therapies.
Clinical management• We were overly optimistic that conservative management would work. It did not, and she is getting a procedure to address her aspiration and feeding dysfunction.
• I feel that a diagnosis of asthma should have been made on his initial admission.
• Readmitted because original problem was not resolved by first admission due to partial treatment.
• Yes, by keeping patient hospitalized longer.
Outpatient services; communication• Ineffective communication among family, primary care provider, and subspecialty team on an outpatient basis. Family’s misperception of the child’s symptoms.
• Currently we do not have a full-time cleft team nurse whose insight and training may have helped prevent this admission.
• Appropriate outpatient response to mother's concerns voiced over phone and outpatient antibiotics. Urine and creatinine not tested when mother called with concerns about worsening appearance of urine.
Previous admission complicationPrevious surgeries and procedures• This patient went home with a peripherally inserted central catheter line that was not necessary for care after discharge and presented with fever in the setting of a central line.
• Patient had prolonged period of being supine after surgery, leading to pressure ulcer. Given his comorbidities, he probably should have been anticipated as being at risk.
• Readmission is likely related to injury to lymphatic ducts at the time of surgery.
New disease processCommunication; resources for outlying centers• The clinic and urgent cares are not comfortable with such complex patients and frequently admit him to the pulmonary service whether he needs it or not.
• Could have been taken care of in her local emergency room, but they wanted her out of their emergency room, so sent her to ours without contacting the nephrologist on call before shipping her, so we had no opportunity to discuss the patient until we heard she was in our hospital a second time in 1 month.
Clinical management• Patient was admitted for fecal impaction. Although this was not directly associated with her bladder surgery, her use of postoperative pain medications may have exacerbated the underlying bowel dysfunction and, if identified earlier, may have been treatable as an outpatient.