The Mrs. Jonesky Case

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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

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