Abstract
Different factors led to worsening of Carla’s condition. Communication lapses contributed to the adverse events as Ana did not call the physician at the dialysis unit to inform him of the importance to monitor Carla’s INR. In addition, the inflexible scheduling hindered Carla from getting the ultrasound test done at the right time and receiving timely care. Another factor is the patient’s failure to follow the discharge instructions. All parts such as the hospital, dialysis center and laboratory should communicate effectively by mailing discharge summaries and calling respective parts to ensure patients are receiving recommended care ...