Case 87

The Case of the Dishonest Employee

Dale Buchbinder

Dr. Jonas was examining a patient in the office who needed a dialysis access procedure performed on one of her arms. Dr. Jones reviewed the vital signs done by Ms. Smith, a med tech/secretary. Her documentation in the medical record clearly stated the blood pressure was equal in both arms. Dr. Jonas performed his own examination and realized that the radial pulse in the left arm felt diminished as compared to the right. After completing a thorough examination, he was still somewhat concerned by the discrepancy between the physical exams and the vital signs placed on the chart by Ms. Smith. He repeated the blood pressures himself. Sure enough, the systolic blood pressure in the left arm was 60 mm/hg less than the right. The patient’s left arm would have been the preferred site to perform an access procedure because the patient was right-handed. Now it was clear only the right arm would be suitable unless another intervention was performed first. If Dr. Jonas had relied on the information placed in the chart he would have conducted an access procedure in the left arm. With a low systolic blood pressure in the left arm, the access would have been doomed to either failure, or given the patient’s physical status, a severe complication such as steal.* Since he was trying to sort through the facts and what happened, Dr. Jonas asked the patient if blood pressure readings were performed in both arms. The patient replied the pressure had only been taken in the right arm. Dr. Jonas confronted his employee and told her that her blood pressures were not correct, and, in fact, the patient had stated that they had not been taken in the left arm. Ms. Smith stated that she was quite busy and felt that these pressures were never different. With her response, she admitted to having falsified the data.

Discussion Questions

1. Summarize the important aspects of this case.

2. Which theory or theories do you believe best explain Ms. Smith’s behaviors?

3. What actions would be appropriate in dealing with such falsification of patient data?

4. Should Ms. Smith be terminated, counseled, or disciplined in some other fashion?

5. What are the clinical implications of Ms. Smith’s actions?

6. What are the legal implications of Ms. Smith’s actions?

7. What should Dr. Jonas do in the future to make sure that this set of events does not recur?

The Case of the Phony PA

As a Senior Investigator at University Hospital, you were awarded a large grant to study the effects of new medications on healing leg wounds. The grant calls for either a nurse practitioner (NP) or a physician assistant (PA) who will be able to document the processes and keep the paperwork up-to-date on the grant. You interviewed several candidates and have found that Charles Tony, a PA, appeared to be the best candidate. His resume indicated that he earned a bachelor’s degree from a prestigious midwestern university, worked several years as an EMT, then went to PA school and earned an associate’s degree as a PA. He presented diplomas and copies of licensure certificates and had excellent recommendations from many reliable sources. This package was presented to you by the Human Resources Department. He was interviewed by several colleagues who would be participating in the study and was hired. He began work and appeared to be doing a good job. After a few months, some strange events started to occur. For instance, the locker he shared with one of the physicians was broken into. Multiple purchases were made on the physician’s credit cards in a very short time. Mr. Tony claimed his wallet had been stolen during that same incident. Other employees stated he was acting somewhat strange around them. He began dating an employee in the institution, then her apartment was broken into. At this point, no one was really suspicious, and Mr. Tony appeared to perform the functions of this job without any problems. Approximately 14 months after he was hired, he did not show up for work, did not answer his phone, and none of the records he was responsible for could be located. You contacted the HR Department and they began an investigation. To everybody’s surprise, you learned none of his credentials was actually checked back to their primary sources. When this check was completed after he disappeared, none of the academic institutions had ever heard of him. His references were all fraudulent. The police searched his apartment and found many missing pieces of University Hospital equipment. Mr. Tony was, however, nowhere to be found. It appears you hired a true pretender.

• Background Statement

• Major Problems and Secondary Issues

• Your Role

• Organizational Strengths and Weakness

• Alternatives and Recommended Solutions

• Evaluation

The Case of the Phony PA

As a Senior Investigator at University Hospital, you were awarded a large grant to study the effects of new medications on healing leg wounds. The grant calls for either a nurse practitioner (NP) or a physician assistant (PA) who will be able to document the processes and keep the paperwork up-to-date on the grant. You interviewed several candidates and have found that Charles Tony, a PA, appeared to be the best candidate. His resume indicated that he earned a bachelor’s degree from a prestigious midwestern university, worked several years as an EMT, then went to PA school and earned an associate’s degree as a PA. He presented diplomas and copies of licensure certificates and had excellent recommendations from many reliable sources. This package was presented to you by the Human Resources Department. He was interviewed by several colleagues who would be participating in the study and was hired. He began work and appeared to be doing a good job. After a few months, some strange events started to occur. For instance, the locker he shared with one of the physicians was broken into. Multiple purchases were made on the physician’s credit cards in a very short time. Mr. Tony claimed his wallet had been stolen during that same incident. Other employees stated he was acting somewhat strange around them. He began dating an employee in the institution, then her apartment was broken into. At this point, no one was really suspicious, and Mr. Tony appeared to perform the functions of this job without any problems. Approximately 14 months after he was hired, he did not show up for work, did not answer his phone, and none of the records he was responsible for could be located. You contacted the HR Department and they began an investigation. To everybody’s surprise, you learned none of his credentials was actually checked back to their primary sources. When this check was completed after he disappeared, none of the academic institutions had ever heard of him. His references were all fraudulent. The police searched his apartment and found many missing pieces of University Hospital equipment. Mr. Tony was, however, nowhere to be found. It appears you hired a true pretender.

Discussion Question:

1.What are the facts in this case?

2. What errors were made in the hiring of Mr. Tony?

3. What are the merits of checking on the background of any employee, especially those entrusted with the care of patients in a hospital or clinical setting?. Whose responsibility is it to check the references?.

4.How could these events have been avoided?

5. Were there red flags that should have altered you to the problem earlier?

6. Provide a detailed plan for evaluation and verification of health care professional's credentials and recommendations to avoid this type of issue in the future.

Case 87

The Case of the Dishonest Employee

Dale Buchbinder

Dr. Jonas was examining a patient in the office who needed a dialysis access procedure performed on one of her arms. Dr. Jones reviewed the vital signs done by Ms. Smith, a med tech/secretary. Her documentation in the medical record clearly stated the blood pressure was equal in both arms. Dr. Jonas performed his own examination and realized that the radial pulse in the left arm felt diminished as compared to the right. After completing a thorough examination, he was still somewhat concerned by the discrepancy between the physical exams and the vital signs placed on the chart by Ms. Smith. He repeated the blood pressures himself. Sure enough, the systolic blood pressure in the left arm was 60 mm/hg less than the right. The patient’s left arm would have been the preferred site to perform an access procedure because the patient was right-handed. Now it was clear only the right arm would be suitable unless another intervention was performed first. If Dr. Jonas had relied on the information placed in the chart he would have conducted an access procedure in the left arm. With a low systolic blood pressure in the left arm, the access would have been doomed to either failure, or given the patient’s physical status, a severe complication such as steal.* Since he was trying to sort through the facts and what happened, Dr. Jonas asked the patient if blood pressure readings were performed in both arms. The patient replied the pressure had only been taken in the right arm. Dr. Jonas confronted his employee and told her that her blood pressures were not correct, and, in fact, the patient had stated that they had not been taken in the left arm. Ms. Smith stated that she was quite busy and felt that these pressures were never different. With her response, she admitted to having falsified the data.

• Background Statement

• Major Problems and Secondary Issues

• Your Role

• Organizational Strengths and Weakness

• Alternatives and Recommended Solutions

• Evaluation

CASE 101

Social Networks and Medicine

Kevin D. Zeiler

The Riverbend Hospital, a hospital located in a rural area of the state, recently purchased laptops for all employees of the hospital system, as well as emergency responders. The goal of the purchase was to streamline medical treatment and information in real time so that patients could receive more timely care. The program has been in place for just over three months with most of the employees feeling that the new system has been a real time-saver. However, a recent leak of patient information has put the program in jeopardy. Because the laptops are provided with Internet access, many of the hospital’s employees have been using them for personal web browsing, social network updating, etc. Ambulance crews have been uploading photos from crash sites, shootings, etc., so that physicians and nurses can be made aware of the mechanism of injury and such. However, an employee in the system recently posted some of those photos to a social network site that many members of the local community share, and it has brought to light an abusive relationship that is taking place in the small community. The photos clearly show the patient and most, if not all, citizens in the small community know her. Furthermore, other providers have started to post comments about her treatment, follow-up care, and other medical conditions. The female patient is currently seeking legal advice and the future of the hospital’s new computer system has been compromised.

Discussion Questions:

1. You are the director of the electronic record delivery program at riverbend and want to see the program continue. However, given the above circumstances, what Act must you rely on to guide you in this process? What does this Act say about the use of electronic medical information?
2. What legal options does the patient have as it pertains to this case?
3. If the program does survive, what can you do as the director to ensure that something like this does not happen again?

BACKGORUND STATEMENT -

MAJOR PROBLEMS AND SECONDARY ISSUES -

YOUR ROLE -

ORGANIZATIONAL STRENGTHS AND WEAKNESS -

Organizational strength:

Organizational weakness:

ALTERNATIVES AND RECOMMENDED SOLUTIONS -

EVALUATION -

A 23-year-old male patient is admitted with a fracture of C6 and C7 that has resulted in quadriplegia. He was injured during a football game at the university where he is currently a senior. His career as a quarterback had been very promising. At the time of the injury, contract negotiations were in progress with a leading professional football team.

1.Use Roy’s criteria to identify focal and contextual stimuli for each of the four adaptive modes.

2.Consider what adaptations would be necessary in each of the following four adaptive modes: (1) physiological, (2) self-concept, (3) interdependence, and (4) role function.

3.Create a nursing intervention for each of the adaptive modes to promote adaptation.

Community health workers were conducting a screening test for diabetes. People who tested positive on the screening test were referred for follow-up testing to confirm if they had diabetes. There were 300 people who tested positive during the screening in the community. Thirty of these people were later found to not have diabetes. There were 500 people who tested negative during the screening in the community. The community health workers later found out that 20 of the people who tested negative during the screening in the community did actually have diabetes.

a. How many false positives were there on the screening test?

b. How many true negatives were there on the screening test?

c. Calculate and interpret the sensitivity of the test. (show your work)

d. Calculate and interpret the specificity of the test. (show your work)

e. Calculate and interpret the positive predictive value of the test. (show your work)

f. Calculate and interpret the negative predictive value of the test. (show your work)

Describe 2 consequences or limitations of false positive test results for a screening test to detect cervical cancer.

Suppose an extraterrestrial anthropologist asks you what type of health system you would build in the United States, if you could start from scratch. You need to 1) describe the health care system and how it would be financed. 2) describe where care would be received and how care would be rationed. 3) discuss production efficiency, efficiency in consumption, and equitable redistribution. How and why is your proposed system better than the current health care system in the United States?

Which of the following is NOT a type of bias?

-Randomization bias

-Misclassification bias

-Confounding

- information bias

- selection bias

Epidemiologists conducted a case-control study of asthma and asked participants if they had ever worked in a factory. They stratified their analysis by smoking. Smoking is associated with asthma and working in a factory.

Odds ratio for smokers = 500x100/150x200 = 1.66

Odds ratio for non-smokers = 250x200/200x75= 3.33

Question- By looking at odd ratios, Do you think that there is confounding, effect modification, or neither in this study?

Venom production in your rattlesnake population has a phenotypic mean of 400 mg, a phenotypic standard deviation of 36 mg, and a narrow-sense heritability of 0.25. The mean generation interval is 2 years. If you perform phenotypic selection by culling the bottom 10% of individuals each generation (i = 0.2), approximately how many years will it take for your population to reach a phenotypic mean of 450 mg?

Explain how 56 is the correct amount of years to reach a mean of 450mg

9. The Health Insurance Portability and Accountability Act (HIPAA) was passed to

10. Which one is an instrumental activity of daily living (IADL)?

a) Bathing oneself

b) Feeding oneself

c) Paying bills

d) Using the toilet

11. Which one is not true of social martketing?

12. Which one is not true of licensure?

Describe the biblical basis for the involvement of Christians in addressing health issues outside the boundaries of their own country.