practice partner
Patient Safety
We use this forum to regularly report on findings from patient safety organizations, expert review
committees of the Office of the Chief Coroner, and inquests.
Woman’s delirium
goes unnoticed
during long
hospital stay
photo: istockphoto.com
photoS: CLAUDIA HUNG
A
review into the death of an
82-year-old woman who suffered
unrecognized delirium for her entire six-month stay in hospital has
prompted a host of recommendations from a
committee of the Chief Coroner.
While the Geriatric Long-Term Care and
Review Committee (GLTCRC) recognized
that the case was complex and challenging for
the health-care professionals, its report stated
that there were significant concerns that must
be addressed.
“The treating health-care team did not
seem to recognize the ongoing delirium after
the first few days in hospital. Instead, the
decedent was treated as though this was her
baseline cognitive state due to dementia,”
stated the report.
The woman had been independent while
living in the retirement home. When she got
sick and arrived in the emergency department
of the hospital, she had a 24-hour history of
an acute change in cognition and behaviour,
on a background of a few weeks decline in
memory.
The patient’s presentation was consistent
with delirium (i.e., fluctuating awareness and
consciousness, confusion out of keeping with
her cognition prior to admission, and frequent agitation and hallucinations). This presentation was out of keeping with dementia,
Issue 2, 2016 Dialogue
Issue2_16.indd 39
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2016-06-16 12:27 PM