The case of Mrs. Jonesky can be classified as a “never event.” The National Quality Forum (NQF) defines a never event as “[1] errors in medical care that are clearly identifiable and preventable, [2] serious in their consequences for patients, and [3] indicate a real problem in the safety and credibility of a healthcare facility” (Youngberg 2011). Operating on the wrong site of a patient is considered a never event. In the case of Mrs. Jonesky, a combination of communication errors and hand off procedures led the surgeons to operate on the wrong site of two patients. The issue of communication was prevalent when the patient arrived at the emergency department and did not receive an interpreter. Providers must offer interpretation services for …show more content…
In the first phase of the University Protocol, the preoperative verification process, “an ongoing process of information gathering and verification, beginning with the determination to do the procedure, continuing through all settings and interventions involved in the preoperative preparation of the patient” should be completed (Malloy). At this time, all relevant documents are available, reviewed, and consistent with each other and with the patient’s expectations of the procedure, including but not limited to the intended patient, procedure, and site. Following, “the intended site must be marked such that the mark will be visible after the patient has been prepped and draped” (Malloy). This mark will allow any and all health care providers to unambiguously identify the intended site of incision. Furthermore, the final step of the University Protocol is the “time out” immediately before starting the procedure. This acts as a “final verification of the correct patient, procedure, and site” (Malloy). The “time out” involves active communication among all members of the surgical team, ensuring that any and all questions, comments, and concerns with the procedure are addressed before the start of the procedure. Following these phases of the University Protocol will ensure that a patient will not suffer from a wrong site surgery, as well as the hospital not be exposed to
First, “duty of care" is one of the elements of a cause of action that occurs when the law recognizes a relationship between two parties. Second, breach of the duty of care is another element that occurs as a result of failure to exercise care in the fulfillment of duties. Causation is the third element in that a breach of the duty of care must be the cause of injury to an injured person in accordance with law. Lastly, damage is an element of a cause of action that can be remedied through the use of money damages.
Hospitals are busy places, and with so much going on it is hard to believe that mistakes are not made. However, there are some accidents that should never happen. Such events have been termed ‘never events’ because they are never supposed to happen. This term was first introduced by Ken Kizer, MD, in 2001 (US, 2012). The Joint Commission has classified never events as sentinel events and asks that hospitals report them. A sentinel event is defined as, “an unexpected occurrence involving death or serious physiological or psychological injury, or the risk thereof” (US, 2012). Never events are termed sentinel events because in the past 12 years 71% of the events reported were fatal (US, 2012). Because these events are never supposed to happen, many insurance companies will not reimburse the hospitals when they occur. A study in 2006, showed that the average hospital could experience a case of wrong-site surgery, one example of a never event, only once every 5 to 10 years (US, 2012). This study illustrates how rare a never event is. Hospitals do not want these never events to happen any more than a patient does. To help prevent these errors, hospitals have created policies that, if followed, will minimize the possibility of a mistake. The consequences of never events are devastating and because of this the goal is to make sure that they are eradicated from hospitals and medical facilities.
It is essential to make sure that the patient is fine once the procedure has been finished and prior to them leaving. If there have been no complications, then the patient will most likely be ok. Nevertheless make sure that the site has stopped bleeding and that they are not feeling faint. If there was any complications, for example, hitting an artery, haematoma or fainting, then make sure you follow the process for dealing with the complication and let the patient know what they need to do if any symptoms
Hinkle, J., Cheever, K., & , (2012). Textbook of medical-surgical nursing. (13 ed., pp. 586-588). Philadelphia: Wolters Kluwer Health
The Lynne Gobbell case demonstrates that many people are not in favor of the purest form of freedom of speech. In this case, Lynne had a ‘Kerry for President’ sticker on her bumper, and although no harm came from this, her boss erupted and demanded she remove the sticker. After denying such a ridiculous request, she was fired immediately. In my opinion, this is outrageous because she was not causing anyone harm, and it affected nothing. People should be able to stand up for what they believe in, and should be able to freely represent what they stand for. Decorating vehicles should never have a negative impact on another person. For example, as a die-hard Dallas Cowboys football fan, I do not start breaking windows when I see other vehicles representing the San Francisco Forty Niners. I may not agree with what they represent, but I will gladly respect their opinions and continue to think freely while cheering for what I believe in. Mills’ harm principle suggests that the actions of individuals should only be limited to prevent harm to other individuals. It is easy to recognize that Lynne is not harming anyone, but instead she is the one being harmed; thus Mill’s would side with Lynne in a heartbeat. Karl Marx’s views on this case do not differ too much on this case as his ideas and beliefs would favor Lynne. His critiques of alienated labor and bourgeois freedom show how badly workers can be treated, as he believes workers tend to be taken for granted and treated badly by the upper class. Marx believes there are many different types of alienated labor and all affect workers in a variety of different ways. Marx and Lynne would both have defended Lynne if they were given such an opportunity to do so.
In “When Doctors Make Mistakes,” Atul Gawande flatly states that “all doctors make terrible mistakes” (657). In doing so he explains certain failures and errors that doctors commit that led to situations that in danger patients. Gawande first mentions a study that found “…nearly
...iately discovered and the patient was fine, but had there been proper communication between the healthcare staff, such blunders could have been avoided altogether (Dolanksy, 2013).
Understanding that all patients needed to be treated justly and given the opportunity to make decisions in their care is important. Not causing harm and preventing them from harm is also the duty of health care workers. These ethical principles are essential to keep in mind with interdisciplinary communication. Ineffective communication has been associated with medical errors, patient harm, and increase length of stay. Failure to communicate properly has been associated with 79% of sentinel events (Dingley, Daugherty, Derieg & Persing, 2008). Good communication has been shown to improve patient satisfaction, increase in patient safety, as well as a decrease in health care costs (Paget et al.,
Hospital medical errors can involve medicines (e.g., wrong drug, wrong dose, bad combination), an inaccurate or incomplete diagnosis, equipment malfunction, surgical mistakes, or laboratory errors. High medical error rates with serious consequences occurs in intensive care units, operating rooms, and emergency departments; but, serious errors that harmed patients may have prevented or minimized. Understand the nature of the error
According to Poorolajal, medical errors occur when health care providers choose inappropriate methods of care or improperly execute an appropriate method of care (Poorolajal, et al. para 5 -10), which could potentially lead to loss of life and severe or permanent trauma to the victim. Valiani et al. argues, “Committing an error is part of the human nature” (540). Valiani et al. insist that no health care practitioner is immune to committing an error event if they demonstrate mastery of their skills (540). However, error in health care systems is dependent on many causes and factors. Management of such factors is essential to reducing the occurrence of errors in a health care system. Therefore, what strategies can medical practitioners implement to reduce medical errors? Medical practitioners can implement strategies such as communication, verification, and eliminating extended work shifts. These strategies are most effective because they help medical providers fulfill their full potential in doing their job in the most effective
In saying 1.5 million Americans have witnessed hospital errors in the care of the medical center or even 40,000-100,000 deaths is a ridiculous amount of faults. Errors should be minimized, especially when dealing with people’s lives. The number of deaths is so high hospitals should take notice and really pinpoint where their facility is miscalculating and create in-service training to all employees and not just the ones that are making the errors but all employees. This will decrease the chances of errors made in the hospital. With continuous training every month there can be a huge change in the number of mistakes. The fact that these inaccuracies are even causing deaths really highlight the importance of the need for a change. Families
Surgical Never Events can happen very easily if procedures to prevent them are not used. Surgical Never Events include foreign objects left inside the patient, wrong site surgery, and performing the wrong surgery on a patient. “There were 148 surgical never events in England between April and September 2013, including one woman who had a fallopian tube removed instead of her appendix” (Nursing Standard, 2014, p.10). It is crucial for these surgical errors to never happen because they are often never caught and can potentially result in a fatality. When patients do not have complications in a reasonable amount of time after surgery the errors are often never found because when they start to cause an issue it is often too late.
The intervention refers to the treatment provided to the population of the study (Riva et all 2012). In this case, the intervention is the suggested compliance of the entire WHO Surgical Safety Checklist versus noncompliance or lack of completing the full checklist. Full surgical team compliance of the checklist provides safety for patients undergoing surgical procedures, appropriate team communication, and beneficial results for patients and staff. It would be advantageous, especially in emergency situations, to implement an assigned RN to be responsible for the checklist to minimize the risk of any mistakes made by the operative staff. Regardless of the severity of the emergency situation, the checklist should be evaluated in order to prevent any further complications or mistakes and to provide accurate team
Time out was done by the anesthesiologist, the circulating nurse, the surgeon, and the scrub tech all pausing before the surgery and verifying the patient’s name and date of birth, the procedure being done, the site and location on the body in which the procedure was being done, and documented the count of all the equipment the scrub nurse had before surgery to compare to after surgery. 5. The patient’s privacy was protected and respected throughout the whole surgical procedure. The staff was very professional and I felt I learned a lot from them during my OR experience. 6. A sponge count is when the scrub nurse counts the sponges that are unused before the surgery she relays this to the circulating nurse and it is documented. After the surgery the count is redone to make sure that there are no sponges left in the patient. 7. The circulating nurse documents the information and signs the chart in the operating room. From pre-op to the operating room the nurses in pre-op gave off report to the circulating nurse by SBAR. From the operating room to PACU the anesthesiologist went with the patient and handed off the patient’s condition and information to the nurse in there. 8. There were no ethical or legal issues that were raised during my observation in the whole surgical process. 9. I learned how the whole operating procedure works from start to finish, all the legal paperwork involved, and how the team interacts and helps each other out to give the patient a safe and
Ensuring proper patient safety in the operation room starts prior to the patient entering the operation room. Special attention is given by the hospital staff to prevent surgical errors. Surgical errors consist of wrong-site, wrong-person, wrong-procedure, and retained foreign object(s). Wrong-patient surgery refers to a surgical procedure performed on an alternative patient rather than the patient who was intended to undergo the operation. The wrong-side surgery means a surgical procedure done on the incorrect extremity of the patient’s body. For example, in one case a patient needed a surgery to remove the left vulva due to cancer. Due to a surgical error, the patient had the right side of the vulva removed by surgeons (PSNet, 2017). The wrong-part surgery refers to a surgical procedure that takes place in the proper region, but at the wrong anatomical part. For example, operating on the incorrect level of the spine. Personnel involved in the care of the surgery patient should