Alicia Cole
Alicia- young adult female, admitted for surgery to remove two uterine fibroids with expected hospital stay of 2 days
Initial Assessment

What do you think is going on with this patient?
(everyone to answer)

Response Discussion ( ~3 min)

5 days post surgery - breathing labored, elevated HR, abdomen red, hard. Patient describes it as “on fire”. Mother notices black dot
Doctor's Visit
Review Assessment
Share what you are most concerned about ?(everyone to answer)
Review Assessment (~3 min)

1 hour later ... black dot has increased in size from a small dot to ~1 inch or 24 cm.

Physician asks Mother (who is visiting) to assist. He opens wound at the bedside – large amounts of grayish, yellowish drainage noted, culture taken. Physician uses previously opened dressing kit from patient’s window seal and begins packing wound. Patient experienced extreme pain with this procedure.


Alicia had the elective surgery in August of 2006

Had a 2 month battle with severe sepsis, pseudomonas, methicillin-resistant staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and necrotizing fasciitis.

… took 3 years to heal.

…. 10 years of weekly medical care including: daily hyperbaric oxygen changer treatments, silver nitrate treatments to wound bed and pelvic floor rehabilitation.
Team Discussion
What can our team learn from this case to improve the care in a similar situation?
Team Discussion (~5 min)
Systems Discussion
What systems do we have in place to prevent this?
(every team member to answer)
What system issues might have contributed to this outcome?
(every team member to answer)
Systems Discussion (~5 min)
- infection prevention
- surgical site infection
- surgical and medical asepsis
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