NR 527 Week 1 Discussion Post on One Lost Message Example

Week 1 Discussion: Initial Post

The Box Marked "Please Call Back With Findings": One Request That Left Our Facility at 1840 and Never Came Back

The Message

I am the nurse practitioner at a 120-bed skilled nursing facility. At 1840 last Tuesday, Mrs. B., 86, who has moderate dementia and takes apixaban for atrial fibrillation, was found lying next to her bed, a small cut over one eyebrow. Because of her anticoagulant, the charge nurse and I agreed she needed a head CT, and she was sent by ambulance to the emergency department. With her went our two-page transfer form. At the bottom is a box our facility added two years ago: "Please call back with findings and any new orders." The charge nurse wrote our direct number beside it and checked it. That box is the message this post follows.

Where It Went and Where It Stopped

The form traveled with the paramedics and was handed to the ED triage nurse at about 1915. The ED physician saw Mrs. B. at 2040. Her CT showed no bleeding, the cut was closed with adhesive strips, and a urinalysis suggested a urinary infection, for which a new antibiotic was started. She returned by ambulance at 0145 with a one-line note: "CT negative, see ED record." No one called. Our night nurse could not see the ED record, did not know about the antibiotic, and gave no dose until I reviewed the hospital portal at 0800.

When I asked, the ED charge nurse explained that our transfer form goes into the paper chart that is scanned the next day. The physician never saw the box. The request did not fail on the way out; it failed at the point where it was filed as a document instead of read as a request.

The cost of that gap was concrete: a missed evening dose of a new antibiotic for a resident with a urinary infection, and a night nurse who had no way to know whether the cut on Mrs. B.'s brow needed checking for bleeding. The ED did its clinical job well. The message about what it had done simply never reached the people who would care for her next.

Why It Matters Beyond One Resident

This is not unusual. In a study of 457 transfers from nursing homes to an emergency department, important information gaps occurred in 85.5% of cases, and even when a standardized form was used, gaps remained in 74.9% (Cwinn et al., 2009). Focus groups with nursing home staff, emergency staff and paramedics found that residents are often moved in both directions without written documentation (Terrell & Miller, 2006). Our form was complete going out. Nothing structured came back.

Question for the group: Pick one message you sent that needed an answer. At what point did it become someone else's document rather than their task?

Reply to Jennifer

You followed a pharmacy clarification request that sat unanswered in a shared inbox. I think you found the same failure point I did: the request arrived, but nobody was named to act on it. Did the inbox have an owner on nights, or only a group name?

Reply to Ahmed

Your example of a consult request from primary care to cardiology that was accepted but never scheduled is interesting because it did come back, as an acknowledgment. The acknowledgment may have made everyone think the loop was closed. Did anyone on your team check for an appointment date, or only for the reply?

References

Cwinn, M. A., Forster, A. J., Cwinn, A. A., Hebert, G., Calder, L., & Stiell, I. G. (2009). Prevalence of information gaps for seniors transferred from nursing homes to the emergency department. CJEM, 11(5), 462-472. https://doi.org/10.1017/S1481803500011660

Terrell, K. M., & Miller, D. K. (2006). Challenges in transitional care between nursing homes and emergency departments. Journal of the American Medical Directors Association, 7(8), 499-505. https://doi.org/10.1016/j.jamda.2006.03.004