Patient Safety/Quality Care/Improvement Case Study
1. Overview of what are medical errors and possible consequences of such errors? The Institute of Medicine (IOM) defines medical errors as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.” Medical errors do not all result in harm or injury. Medical errors that cause injury or harm are sometimes called preventable adverse events – that is the injury is thought to be due to a medical intervention, not an underlying patient condition. Errors resulting in serious injury or death are considered “sentinel events” by the Joint Commission. These signal need for immediate response and analysis to identify all factors contributing to the error and reporting to the appropriate individuals and organizations to implement or guide system improvements. The types of error or harm are further classified regarding domain, or where they occurred across the spectrum of healthcare providers and settings. Agency for Healthcare Research and Quality (AHRQ) research has shown that errors can occur at any point in the health care delivery system. Medical errors most frequently result from systems errors—organization of health care delivery and how resources are provided in the delivery system. 2. What type of error occurred in the case study and where was the breakdown in communication? In this case study a medical error occurred because Dr. Summer’s nurse and the G.I. Lab failed to identify and confirm the Right Patient when scheduling a lab exam. A series of communication errors and lack of appropriate follow-up communication occurred in this case study. Dr. Summer’s nurse did not have the G.I. Lab scheduler verbally confirm both the patient’s and physician’s names - only the prescribed tests were confirmed by the nurse and scheduler during their phone conversation. There was also no confirmation of the scheduled procedure and appointment sent or communicated by the facility to the requesting physician’s office. There was no confirmation of the scheduled procedure and appointment communicated or sent in a timely manner to the patient. There was no follow-up by Dr. Summer’s office to confirm the appointment on behalf of the patient nor was there any follow-up with the patient. When the GI Lab nurse called the patient one day prior to the procedure to confirm the appointment, the GI Nurse neglected to even mention the patient’s physician name. She only mentioned the procedure had been scheduled by patient’s physician and provided name and address of the GI lab and physician conducting the procedure. How was patient safety compromised?
The patient was misidentified for the procedure and nothing was done to follow-up and check to confirm that the correct physician had ordered the procedure for the correct patient who was scheduled for the procedure. The risk related to the procedure itself, fortunately for the patient and provider, was very low in this case study. 3. Do you think patient harm occurred?
In this situation there was no evidence of physical or emotional harm to the misidentified patient undergoing the procedure. The side effects of esophageal manometry are minor and may include mild sore throat, rare nose bleed and uncommonly sinus problems due to irritation and blockage of the ducts leading from the sinuses and nose. None apparent side effects or potential problems were experienced by the patient in this case study and the patient did not appear upset with the scheduling mix-up. Patient harm could, however, result to Dr. Summer’s patient, Melissa Kain, who was not scheduled for the prescribed G.I. procedure, as a delay in lab studies could prove problematic. 4. a. Discuss how the QSEN competencies could have helped to prevent this situation from happening? Other than the initial patient visit and appointment made with the G.I. lab by Dr. Summer’s nurse, there was no follow-up whatsoever with the client by the nurse or the...
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