Patient Safety: Four Easy Pieces

Could this happen in your work setting?

An inmate was evaluated for a heart condition and found to have several blocked coronary arteries. He was scheduled for cardiac stents at the local hospital where the prison had an agreement for services. He had the stents placed and returned to his cell block the following day. He returned with one discharge order sheet that included a note at the bottom to “see page 2”. No second page was included with the discharge order sheet. A nurse practitioner reviewed his one page of discharge orders, confirmed them, and wrote on the medical order sheet that there were no changes to be made. This was interpreted to mean no changes to the patient’s pre-procedure medications and he was returned to his prior medication regimen. Meanwhile the 2nd page of the discharge orders was faxed directly to the prison medical director. The medical director reviewed them during office hours the next day and placed the orders in his outbox for transcription and return to the chart. That order sheet never got to the chart. The patient told the medication technician who administered medications on his housing unit that he was supposed to be getting Plavix after his procedure. The med tech told the patient that there was no order for Plavix and he was mistaken. The patient continued to ask about the Plavix at subsequent medication lines with similar response. One staff member told him the medication was nonformulary and there might be a 3-5 day delay in obtaining it. Six days after the procedure the patient had crushing chest pain and returned to the hospital where it was found that two of his stents had occluded and required emergency treatment. Fortunately the patient survived the experience.

In a previous post I explained how, even though I am nervous about crashing when flying, there are more deaths each year from clinical errors than from airplane crashes. We would do well to focus in correctional health care on patient safety as there is such a significant return on our time investment. But, where do we start?

Patient safety experts developed a 3-part model for explaining components of a safety paradigm in the traditional health care setting. I adapted this model to the correctional setting and added a 4th element – the care environment to the original representation. As many of us practicing in the criminal justice system know, the environment in which we work has a significant effect on care delivery and outcomes.

Consider how each of these four patient safety elements might have affected the outcome of the case presented above.

Environment of Care

The environment is primarily the organizational culture of the workplace but can also include the physical environment such as the design of the care delivery setting and the available equipment and supplies. The secure environment of the criminal justice system adds intensity to the environment of care by also imparting a unique set of values and cultural norms. There can be a true culture clash or a struggle with dual loyalties among the care staff. We often talk about the impact of the security culture on health care delivery. The inmate culture also has an effect on patient safety. There develops a culture of mutual mistrust that can poison the patient-practitioner relationship. How might the organizational culture in the case presentation have affected the actions of the care team?

Systems for Therapeutic Action

Patient care is delivered through a complex system of intertwined processes. Patients and practitioners interact with these systems within the environment of care. Patient safety principles can increase the reliability of care systems; reducing error and improving outcomes. Do you think there were some real system failures in the case above?


The patient is also a vital part of the safety framework. Interacting with health care workers and the systems of therapeutic action within the environment of care, patients have opportunity to actively participate in and monitor care delivery. There are many barriers to engaging patients in the criminal justice system that must be considered and overcome. Was the patient a factor this critical incident?


The competence and judgment of health care staff is a major factor in patient safety. Staff interact with the patient and take therapeutic actions to deliver health care. Internal and external factors such as fatigue, work stress, impairment and shift rotation affect our abilities to deliver safe care. Emotional issues like burn out, vicarious trauma and compassion fatigue affect our clinical judgment. Could any of these be attributed to the actions taken in this case?

By using this model of patient safety in correctional health care, a full evaluation of the missing Plavix case can be undertaken and system improvements initiated.

Share your thoughts on what you would investigate further in the comments section of this post.

3 thoughts on “Patient Safety: Four Easy Pieces

  1. If the discharge orders indicated a second page, then the nurse pratitioner who received and acted on that incomplete order, should have obtained the complete order before taking any other action.


  2. Pingback: Patient Safety – What’s Holding You Back? | Essentials of Correctional Nursing

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