Case Study # 2 Prelude to a Medical Error In the case study “Prelude to a Medical Error-Case for Chapters 4 and 7” by Sheila K. McGinnis. Nurse Karing made a cognitive biases preconception of what she knew about thrombosis and connected to Mrs Bee symptoms of a thrombosis in her left calf and proceed to order a STAT venous Doppler X-Ray to rule it out. She also Dr. Cural notify about the thrombosis in Mrs. Bee’s left calf. Dr. Cural was upset when nurse Karing called him about the clot in Mrs. Bee left calf and told her to cancel the test. I think Nurse Karing could have challenged Dr. Cural or talked to another doctor since Dr. Cural did not want to listen to her. Dr. Cural made an assumption about nurse Karing being an incompetent nurse. Instead of Dr. Cural saying nurse Karing incompetent he could have said “I am glad you called me about Mrs. Bee, a thrombosis can be a very serious problem please order the venous Doppler test right away”. Dr. Krisis from the ER made an assumption when she said the “someone must have not had time again to …show more content…
In the CQI approach it will identify and address problems in the hospital work process by using the five dimensions of the CQI model: (1) process focus to develop high quality health care, (2) focus on the customer, (3) using data to make all quality improvement decisions to reduce uncertainty and provide evidence to convince skeptics that a process problem exists, (4) employee empowerment by using quality improvement teams to improve the work environment and reduce errors, and (5) strategic use across the organization by using the FOCUS -PDCA framework. FOCUS (Find , Organize, Clarity, Understand, and Select), and using quality improvement tools such as a check sheet. A cheek sheet will make sure things are getting done, improve safety, and reduce medical
I chose not to use any of the prompts provided, but instead connect the article to what I learned in my sociology class lass quarter. In class we watched part one of film series of Unnatural causes, titled Unnatural Causes: Is Inequality Making us Sick "In Sickness and in Wealth". While reading the article this reminded me about the cases studied in the film to see whether wealth inequality contributes to making people sick. In the film they focused on the social determinants of health, wealth and education. In both the article and part one of the film Unnatural Causes they focused on three different individuals and how their health are affected by they choices they make and the access they have to care.
There are a few types of medical errors discussed in Patient Safety Principles & Practice. One of them is an error of execution. An error of execution is when a correct action does not proceed as intended. It is a failure of a planned action to be completed as first intended. It occurs unintentionally during an automatic performance of patient care. This error is almost always observable at the patient and caregiver interface.
To understand the strategies being adopted in various healthcare facilities in order to improve their scores on quality measures and if these strategies have proved helpful in improving the over quality of care.
The NHS change model has been selected for this quality improvement. The NHS change model consists of eight dimensions, which are described as a useful tool to enhance change. This model has been identified as being effective in health care organisations, encouraging the use of teamwork to implement systematic improvements.
Today, medical error has become a major and important challenge to health care systems across the globe. This is because medical errors often lead to harm that may also be non-repairable (Valiani et al. 540; Denham “Chasing Zero”). In 1999, the Institute of Medicine published a report that indicated that medical error in hospitals accounts for between 48,000 and 98,000 deaths annually (Swift et al. 78; Barger et al. 2441). As such, reducing the occurrence of medical errors has become an international concern. Poorolajal defines a medical error as “an act of omission or commission in planning or execution that contributes or could contribute to an unintended result.” (Poorolajal, et al. para 5 -10). In this case, it’s very important to acknowledge
The purpose of this paper is to identify a quality safety issue. I will summarize the impact that this issue has on health care delivery. In addition, I will identify quality improvement strategies. Finally, I will share a plan to effectively implement this quality improvement strategy.
There was inappropriate staffing in the Emergency Room which was a factor in the event. There was one registered nurse (RN) and one licensed practical nurse (LPN) on duty at the time of the incident. Additional staff was available and not called in. The Emergency Nurses Association holds the position there should be two registered nurses whose responsibility is to prov...
As humans when we are faced with any psychological or emotional problems, our initial thought is to turn to a therapist, doctor or any other health practitioners. Our initial thought when we are faced with problems regarding our health is to turn to a health professional because for ages that’s how it has been. When it comes to our health, health professionals nowadays do more harm than help. Many might disagree, but often patients are misdiagnosed with mental illnesses they do not have. Misdiagnosis occurs when a therapist or other health practitioners decide that a patient is suffering from a condition that he or she may not be suffering with. When misdiagnosed, patients are given unnecessary treatment, which could potentially
A hospital is a difficult place to run because there so many aspects to manage. There are many types of doctors and nurses, and so many departments in this type of facility. The patients come in a wide variety of different ailments, needs, colors, sizes, personalities, and beliefs. Not to mention, with all of the equipment, devices, and people coming and going a hospital can seem like a small town in itself. That is why it will take a group effort, open communication, and positive reinforcement to keep it running smoothly. I will address this case study by identifying each problem, advise an adequate solution for each problem, and give a reason for each solution.
“When Doctors Make Mistakes” narrates an event where the author Atul Gawande, a doctor, made a mistake that cost a women her life. He relates that it is hard to talk about the mistakes that occurred with the patient's family lest it be brought up in court. In that instance the family and doctor are either wrong or right, there is no middle ground in a “black-and-white mortality case”(658). Even the most educated doctors make simple mistakes that hold immense consequences but can only speak about them with fellow doctors during a Morbidity and Mortality Conference.
Quality care, safe practices and principles, and accountability constitute the foundation of any health care organization (Huber, 2014). Addressing patient safety issues and improving health care quality may include reorganizing operations to improve efficiency, coordinating care with interdisciplinary team members, and using information technologies (Wang, Cha, Sebek, McCullough, Parsons, Singer, & Shih, 2014). In this paper, I will review my organization’s quality program goals, objectives, and management structure, how quality improvement (QI) projects are selected, managed, and monitored, and how nursing staff are trained and supported in
It is shocking to know that every year 98000 patients die from medical errors that can be prevented(Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.), 2000). Medical errors are not a new issue in our healthcare system; these have been around for a long time. Hospitals have been trying to improve quality care and patients safety by implementing different strategies to prevent and reduce medical errors for past thirty years. Medical errors are the third leading cause of death after heart disease and cancer in America (Allen, 2013). In addition medical errors are costing our healthcare system an estimated $735 billion to $980 billion (Andel, Davidow, Hollander, & Moreno, 2012).
TQM is about improved customer satisfaction so it then offers the prospect of a great market share and profitability. Some hospitals are not quite worried about what their “customers” think because eventually they will get their money. With research, I have found a consensus that TQM can be an important role of a hospital’s competitive edge in the quality management of the healthcare system. With TQM in any situation, there needs to be a high quality of management and leadership. Without this, things will never change and grow. Also, switching positions up could help to increase the amount of knowledge and new ideas. Total quality management needs to include top-management leadership and support, employee involvement, systems thinking, continuous improvement and data-based decision
Continuously improvement in the quality of patient services health care centre achieves the goals and services for the managing people. Continuous improvement of quality is a structure of process for involving personnel planning and executive for a specific structure in order to improve the quality of health. Change need to improve the structure of organization and sustaining long term process of health care centre. Management focuses on target improvement and has larger impact on actions. Management has eliminated to cause problems that usually involve incremental innovation. Continuous improvement has philosophy that permits the different factors and involves to find the labor of material.
The problems of healthcare that impact quality such as medical errors, health insurance, shortage of healthcare personnel are issues that contribute to a lack of trust in health care systems. Rendering quality care should be appropriate to the need and specific actions taken in accordance to the individual need. Meltzer & Chung (2014), suggest that although quality improvement may sometimes reduce costs, the financial resources, time, and effort available for quality improvement are limited-whether within a single hospital, a payer network, a state, or a