Preview

Wrong Site Surgery

Good Essays
Open Document
Open Document
563 Words
Grammar
Grammar
Plagiarism
Plagiarism
Writing
Writing
Score
Score
Wrong Site Surgery
Background
According to Sollecito and Johnson, 9.2% of the world’s hospital patients are harmed during the care process, and 7.4% of this harm leads to death. Mr. Smith became one member of this 9.2% when the healthcare team assigned to treat his injury operated on the wrong knee. In an attempt to alleviate similar situations from occurring in the future, the healthcare organization at the crux of this occurrence wants a team formed for analysis purposes, to ensure this does not happen again. This team will need to consist of qualified team members that have the ability to communicate well and create lasting quality improvement tools.
Team Members
Sollecito also states that the clinical microsystem should be used as a unit of research, analysis, and practice. Key to the formulation of a good team to analyze accidents like that experienced by Mr. Smith is having knowledge of the procedure and the staff generally required to perform that procedure. Additionally, it would be necessary to find personnel that understand the etiology of the incident in addition to being unbiased personnel so that accurate solutions could be derived. Based on that information the team should have an attorney to determine the legal ramifications, an orthopedic surgeon as their specialty would be in conducting this type procedure, a surgical nurse, a department head and a surgery tech. This diverse makeup would consist of personnel on both the sharp and bump ends of service delivery while providing subject matter experts on each step of the procedure. Just as important as their knowledge when selecting a team is followership. It will be important to have team members that are able to take guidance (Zoheir, et al)

Fostering Communication
In an effort to foster communication “timely, accurate, useful and credible communication is critical to maintaining a cohesive team environment and achieving project success.” Goals and strategy must be made clear and the sharing of



References: Ezziane, Z., Maruthappu, M., Gawn, L., Thompson, E. A., Athanasiou, T., & Warren, O. J. (2012). Building effective clinical teams in healthcare. Journal of Health Organization and Management, 26(4), 428-436. doi: 10.1108/14777261211251508 Flynn, A. B., & Mangione, T. J. (2008). Five steps to a winning project team. Healthcare Executive, 23(1), 54-55. Retrieved from http://search.proquest.com/docview/200343997?accountid=32521 Sollecito, William A., Julie K. Johnson. Continuous Quality Improvement in Health Care, 4th Edition. Jones & Bartlett Publishers, 2011-09-01.

You May Also Find These Documents Helpful

  • Powerful Essays

    Wittkofski, D.L. (2013). The Important Health Care Team: Risk Management and Quality Improvement. Retrieved from http://hitnots.com…

    • 1958 Words
    • 7 Pages
    Powerful Essays
  • Good Essays

    Huntsville Hospital strives for perfection as well, unfortunately “never events” have occurred within the walls of the hospital. The National Quality Forum literally defines a “never event” as a preventable adverse event occurring in a health care setting that should never happen; like, wrong site surgery, patient falls, and medication errors as examples (Gitlow et al., 2013) A patient admitted to the hospital to receive right wrist surgery woke up with surgery to the left wrist. The event was researched, evaluated, reported, and resulted in changes within the institution. A malpractice case filed against the surgeon and the hospital existed and was settled. The adoption of the mandates of JCAHO allowed for implementation within Huntsville hospital to prevent wrong site surgery consists of many valuable steps such as; asking the patient what surgery and where, marking the surgical site with a permanent marker or using the alternative site marking form to identify, limb alert bands, and also the time-out, allowing anyone involved in the patient care to stop the procedure to ensure accuracy. The responsibility to improve quality patient care is assigned to each individual employee that works for a facility and will proceed in continuing to develop even higher quality, on top of the existing quality, CQI (Hashmi…

    • 1016 Words
    • 5 Pages
    Good Essays
  • Better Essays

    Wrong Site Surgeries

    • 1338 Words
    • 6 Pages

    Wrong site surgeries are very rare, but sometimes wrong site surgeries happen. The wrong site surgeries have damaging results for the patient and pose a huge safety problems within the organization. Usually communication breakdown is considered the main cause of wrong site surgeries in the surgical team. The Joint Commission 's universal protocol of "time out" is a very important and a helpful tool in preventing the wrong site surgeries, wrong person surgery, and wrong procedure.…

    • 1338 Words
    • 6 Pages
    Better Essays
  • Good Essays

    The disadvantage of Dr. Ruiz waiting until the follow up to inform the patient about the error and the fact that the patient needs more surgery runs the risk of compromising the physician and patient relationship. That relationship is built on trust. Patients trust that the physician is skillful, knowledgeable, and trustworthy. Also, the patient may become angry, and angry enough to initiate a lawsuit. Even worse, the patient may not trust any medical professionals and choose not to seek medical attention for other conditions. Also, the patient could have become more ill from the lack of treatment. The only advantage of waiting for the follow-up to discuss more surgery is that the patient may have suffered more harm undergoing anesthesia for a longer period of time. This is also a disadvantage of returning the patient back to surgery once the mistake was discovered, during the same event. The advantage of returning the patient to surgery is that it strengthens the physician and patient relationship. The physician recognized the error and desired to fix the error, which may appear noble in the eyes of the patient.…

    • 448 Words
    • 2 Pages
    Good Essays
  • Best Essays

    According to Barnsteiner (2007), “The work of the Institute of Medicine (IOM) and others has clearly demonstrated that when healthcare professionals understand each others’ roles and are able to communicate and work together effectively, patients are more likely to receive safe, quality care” (p. 144). There are many good practices to consider when evaluating the roles and responsibilities of an interprofessional team member. This paper will look at four interdependent strategies; team member roles must be clearly defined and articulated, there must be an understanding and respect for each other’s roles, there must be an appreciation of each other’s scope of practice, and a willingness to learn about and how other members’ roles compliment your own. Although these strategies can be used for all types of interprofessional teams their use in the healthcare setting will be highlighted.…

    • 2115 Words
    • 9 Pages
    Best Essays
  • Best Essays

    McLaughlin, C. P., & Kaluzny, A. D. (2006). Continuous quality improvement in health care: Theory, implementations, and applications (3rd ed.). Sudbury, MA: Jones and Bartlett.…

    • 2196 Words
    • 9 Pages
    Best Essays
  • Better Essays

    Sollectito, W. A. (2013) McLaughlin and Kaluzny’s Continuous Quality Improvement in Health Care, 4E ISBN-97807637781545 from University of Phoenix Course Material.…

    • 1541 Words
    • 7 Pages
    Better Essays
  • Powerful Essays

    To prevent harm to both the patient and us, it is important to recognise not only what can go wrong but also how and why it may go wrong. Think through the activity within the setting of the physical and emotional environment, and the culture of the organisation and the staff who complete the activity. Take into consideration things that have gone wrong in the past and near miss incidents.…

    • 2311 Words
    • 10 Pages
    Powerful Essays
  • Better Essays

    McLaughlin, C., & Kaluzny, A. (2006). Continous quality improvement in Health Care (3rd ed.). Sudbury, MA: Jones and Barlett.…

    • 1713 Words
    • 6 Pages
    Better Essays
  • Good Essays

    Physicians, nurses, pharmacists, technicians, and other health professionals must coordinate their activities to deliver safe and efficient patient care. (Baker, 2006)Health care workers perform interdependent tasks (e.g., a surgeon cannot operate until a patient is anesthetized) while functioning in specific roles (e.g., surgeon, surgical assistant, anesthesiologist) and sharing the common goal of safe care. (Baker, 2006)However, despite the importance of teamwork in health care, most clinical units continue to function as discrete and separate collections of professional. This is partially due to the fact that members of these teams are rarely trained together; furthermore, they often come from separate disciplines and diverse educational programs. (Baker,…

    • 1163 Words
    • 5 Pages
    Good Essays
  • Good Essays

    A team of various health care professionals collaborate together because it greatly increases the level of care provided to patients through the use of inter professional practice/communication. “In order to succeed in today's health care environment, Interprofessional teams are essential.” (Nester, J 2016 pg. 128)…

    • 863 Words
    • 4 Pages
    Good Essays
  • Best Essays

    Executive Summary

    • 2477 Words
    • 9 Pages

    Sollecito, W. A. and Johnson, J. K. (2013). McLaughlin and Kaluzny 's Continuous Quality Improvement In Health Care (4th ed.). Jones and Bartlett Publishers.…

    • 2477 Words
    • 9 Pages
    Best Essays
  • Satisfactory Essays

    The inherent complexity of the preoperative environment combined with utilization of intricate state of the art (not to mention expensive) medical/surgical equipment, consequently, creates a lapse in performance competency of the preoperative team.…

    • 74 Words
    • 1 Page
    Satisfactory Essays
  • Best Essays

    Environmental Proposal

    • 1674 Words
    • 7 Pages

    References: Healthfield, S. (2009). About.com: Human Resources: Twelve tips for team building. Retrieved October 31, 2009, from http://humanresources.about.com/od/involvementteams/a/twelve_tip_team_3.htm…

    • 1674 Words
    • 7 Pages
    Best Essays
  • Good Essays

    The interdisciplinary team is essentially variable in its number of members, which may consists of five to seven members, namely, a physician (e.g. pulmonologist), a nurse (e.g. RN or LPN, or both), a non-healthcare specialist (e.g. bioethicist), a clinical quality expert, and an emergency technician. The primary criterion is their close association with the actual patient care situation and the specific incident (Davis, et al., 2008).…

    • 882 Words
    • 4 Pages
    Good Essays

Related Topics