Patient with Spinal Cord Injury and Implanted Metal Rods Receives NO Antibiotics During Invasive Surgical Procedure

Kitty Campaign: I think it's important to Patient Safety for all documents that caregivers use during procedures and interactions with Patients to be ACCURATE in particular, accurate with regard to the Facts about the Patient and the Patient's health history, physical condition, etc. In that way, the people who have direct contact with the patient, nurses, physicians, phlebotomists, etc. might have appropriate information to direct their work and care. There are some obvious problems you can identify easily when you look through your own records. It's not so difficult. After reading a few records yourself, you will become familiar with how the documents are organized and what is in the documents. It will be easy to notice how important information can be omitted, carried over from other patient documents, or incorrectly noted in the chart. When a medical staff person has limited time, and goes from patient to patient, with workflow interrupted many times during a shift and across days while a patient is resident in a hospital or nursing home, there are many opportunities for confusion and errors to occur. A popular example involves medications errors. It's very easy to follow the flows of medication errors and many efforts are made to avoid these errors. However, there are many other easy to detect situations where errors can occur; even though systems have not been designed to avoid these errors. For example, this PROCEDURE document from the HOSPITAL indicating that the patient having a procedure has NO IMPLANTS. I find it curious since the HOSPITAL'S RADIOLOGISTS CONTINUALLY IDENTIFY METAL RODS AND IVC FILTERS IN the same patient's studies. This is one way that the care and management of the patient's case is continually going awry. Precautions should be taken with anybody who has an implant to avoid infections and the HOSPITAL RECORDS for this Patient NEVER IDENTIFY that the patient has IMPLANTS. In this chart, the patient was already resident in the facility for 18 days, yet nobody corrected the facts of the patient's condition and risk factors. The patient has also been diagnosed with resistant organisms during this inpatient stay, yet physicians have noted in the chart they are of no importance and may represent COLONIZATION. The nurses have inserted catheters to flush out the patient's ileal conduit bypass during this inpatient stay. If the chart had indicated a metal implant, the nurse would have a chance to correct the oversight of ordering flushing of the ileal bladder without prophylaxis antibiotics and notify the physician the patient needs antibiotics prophylaxis for the procedures. Metal implants can become infected very easily with few bacteria. Bacteremia is an indication for antibiotic care when a patient has an implant including 'metal rods in the spine'. It's very difficult to get infected metal rods out of the spine of a patient with a spinal cord injury and has an infection. It's a serious complication of care. The patient has infection and no antibiotics. In addition, the patient might be taken accidentally to the MRI for radiological studies. If the notes in the chart accurately indicated the metal rods implanted or the IVC filter, anyone ordering a radiology study would be made aware. Anyone transporting the patient to radiology would be aware and correct any order for MRI. The fact the chart does not indicate metal implants also prevents the physician from considering infected implant when diagnosing the patient's symptoms, and counseling the patient about how to avoid infections that might compromise his life.