A 64-year-old woman suffered a compound fracture of the femur in a motor vehicle accident. On admission to the emergency department, she was asked about medications she takes at home which she reported to be Fosamax (alendronate sodium) 70 mg by mouth once a week and Synthroid (levothyroxine) 75 mcg daily. She proceeded to the operating room quickly for an open reduction internal fixation of the right femur. During the surgery she had an unexpected complication of bleeding and required a transfusion of 2 units packed red blood cells. Postoperatively, she was transferred from the post anesthesia care unit to the ICU for a higher level of care than was anticipated for the recovery period due to concerns of further bleeding. It was identified in the ICU that the patient normally takes daily aspirin for arthritic pain which was not reported prior to the surgery because the patient didn’t think of aspirin as a medication when asked.

1.

How was patient safety compromised in this situation?

2.

What processes could have provided a higher level of safety for the patient?

3.

What actions can be taken to improve the quality of care and prevent this type of error in the future?