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This WebM&M describes a 78-year-old veteran with dementia-associated aggressive behavior who was hospitalized multiple times over several months for hypoxic respiratory failure and atrial fibrillation before being discharged to a skilled nursing facility. The advanced care planning team, in consultation with palliative care and ethics experts, determined that transition to hospice was appropriate. However, these recommendations were verbally communicated and not documented in the chart.

Nurses play a critical role in patient safety through their constant presence at the patient's bedside. However, staffing issues and suboptimal working conditions can impede a nurse’s ability to detect and prevent adverse events.
Lane SJ, Troyer JL, Dienemann JA, et al. Health Care Manag Rev. 2014;39:340-351.
According to this study, dose omissions were the most common medication errors occurring during transitions to nursing home care. However, the wide range of errors detected suggests that multifaceted interventions would be needed to improve medication safety. A prior AHRQ WebM&M interview and its accompanying perspective discuss safety in nursing homes.
Following surgical repair for a hip fracture, a nursing home resident with limited mobility developed a fever. She was readmitted to the hospital, where examination revealed a very deep pressure ulcer. Despite maximal efforts, the patient developed septic shock and died.
Scott-Cawiezell J, Pepper GA, Madsen RW, et al. Clin Nurs Res. 2007;16:72-8.
This study investigated whether type of credentials affected rates of medication errors and found no significant difference. However, the authors noted that nurses were interrupted more often during medication administration.
Bypassing the safeguards of an automated dispensing machine in a skilled nursing facility, a nurse administers medications from a portable medication cart. A non-diabetic patient receives insulin by mistake, which requires his admission to intensive care and delays his chemotherapy for cancer.