Case Study

Daniel Burgess is a 65-year-old male with chronic kidney disease. Mr. Burgess lives at home alone. He often forgets to take his medications. Mr. Burgess previously had an acute episode of kidney failure requiring hemodialysis.

Mr. Burgess develops end-stage kidney failure and is admitted to the hospital.  The nephrologist tells him that he requires a peritoneal dialysis catheter. Later, a surgeon explains to him the reason for the procedure along with the risk and complications. Mr. Burgess reluctantly agrees. The operating room (OR) nurse prepares him for the procedure and performs a pre-procedure questionnaire. After the procedure, Mr. Burgess is transferred to a nephrology unit. You are the nephrology nurse who will be providing care for Mr. Burgess. You receive a detailed report from the OR nurse.

You introduce yourself to Mr. Burgess, take his vital signs and perform an initial head-to-toe assessment. You demonstrate the first peritoneal dialysis exchange and educate Mr. Burgess about exchanges at home. You also educate him on being aware of the signs and symptoms of infection. After a few days in the nephrology unit, Mr. Burgess is ready to be discharged home with homecare services and support. You discharge him home on Friday afternoon and assure him that the hospital will set up the homecare service to perform the next peritoneal dialysis exchange for him.  Usually, the social worker makes this referral to a home care service. You place a note on the social worker’s desk and write “Please set up home care services for Daniel Burgess MRN #1220932 for Saturday, November 16th”.

Saturday afternoon arrives, and Mr. Burgess still has not heard from the homecare service or the hospital. He gets worried that they forgot about him. He calls the homecare service agency and they state “Sorry we don’t have your information on record”. He calls the hospital to follow up. The nurse from the previous day and the social worker were not back at work. The charge nurse is unaware of the circumstances. They have no choice but to call you, on your day off, to find out whether the referral was made. You reply, “Yes, I put a note on the social worker’s desk”. The unit finds that the note was not received by the social worker, as she had to leave work early. Due to the miscommunication, and the referral not being made, Mr. Burgess did not receive his peritoneal exchange on the Saturday when it was supposed to be due.