Incident Report


Mrs. Williams is a 65 year old patient; she is in room 132 and lives in a long-term facility because she is unable to care for herself. Currently, she goes five times per week for chemotherapy and also takes antioxidant n-acetylcysteine to treat memory loss.

On July 23 Mrs. Williams was ready to go to her chemotherapy session; her vital signs were normal and she did not complain about dizziness or any other malaise. Following her chemotherapy session Mrs. Williams sat in a wheelchair and was alone for a few minutes, while her nurse contacted the nurse station so that the patient could return to her room. Mrs. Williams, however, did not wait for her nurse to arrive and attempted to go back to the ward on her own. Unfortunately, she could not control the wheelchair and hit a wall, trying to make a left turn; as a result, the woman fell on her right side. Two nurses stationed at the nurses’ station observed this incident. Her right leg (RL) and right arm (RA) were under the rest of her body; the patient suffered great pain and even cried. The nurse quickly called an ambulance to take Mrs. Williams to the hospital; her vitals were BP, 95/70, T 95, P 78, R 14; the patient’s range of motion could not be assessed due to the fact that she was in great pain. Ultimately, the cause of the incident was the patient’s sudden decision to handle the wheelchair and the impact while trying to make a turn.

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Type of Incident

Evidently, the type of incident was due to patient’s failure to comply with the nurse’s instructions. Describing the incident, it should be noted that prior to the incident the patient displayed normal vital signs and did not complain about any dizziness or anything else. It is equally important to note that the patient was instructed to hold still and wait for the nurse.  As for the incident itself, it is important to indicate that the patient tried to mobilize the wheelchair herself; she attempted to go back to her room on her own but miscalculated the turn and hit the wall, provoking the accident (a fall that was witnessed by two nurses). Finally, giving the post-fall information, the patient was lying on her right side with her RL and RA under her body. She was crying, and even though her vitals were still within normal limits, it was impossible to assess her range of motion due to her pain and position. In addition, it should be noted also that the patient’s husband and attending physician were called simultaneously with the ambulance.

As it was already mentioned, two nurses witnessed the accident; the cause of the incident was the wheelchair’s collision with the wall (because the patient miscalculated the turn). Discussing contributing factors, it is not clear whether chemotherapy medication might have caused dizziness or any other condition impeded Mrs. Williams from avoiding the collision. Furthermore, her BP was always within normal limits.

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