Instructions: Spend 5-10 minutes reviewing the case below and considering the questions that follow. Case Study 1
John L Smith is admitted to a midsize urban hospital for ambulatory left knee replacement on the same day that John R Smith is admitted for ambulatory left hip replacement. Both surgeries were scheduled to be performed by the same orthopedic surgeon and surgical team. The same admitting nurse performs the verification and reconciliation process in the preoperative area and the patients wait to be called for surgery. The surgeon’s first surgery ran late so his entire surgical schedule was delayed for the day. Once his first surgery was completed, he left the ambulatory surgery area to perform emergency surgery on an accident victim. The admitting nurse informs James R Smith that his surgery needs to be rescheduled. When the orthopedic surgeon arrives back to the ambulatory surgery area, John L Smith has been prepped for left hip surgery by the surgical team and the surgery proceeds. It is only after the surgery that the team realized that the surgical site was never marked, the wrong chart traveled with the patient to the operating room, and in the rush to perform the surgery, no verification process was undertaken in the operating room.
Review the 24 analysis questions from the Joint Commission Framework for Root Cause Analysis and Corrective Actions to identity potential root causes of errors highlighted in this case.
1. Were there any steps in the process that did not occur as intended?
2. What human factors were relevant to the outcome?
3. What are the other areas in the healthcare organization where this could happen?
Instructions: Spend 5-10 minutes reviewing the case below and considering the questions that follow. Case Study 2
A ten-year-old boy was brought to a clinic by his parents. The child had a running nose for the past ten days. The nurse was out sick at the time of the visit, and the receptionist was assisting the physician. On examination, the physician diagnosed simple allergic rhinitis and advised the parents to use over-the-counter antihistamine cetirizine. The parents were provided with a post visit summary and instructions. After two days, the mother returned to the clinic and reported that the boy was lethargic. The clinic’s front desk said that they would convey the information to the physician, who was very busy that day. The physician later said that it is typical for children taking cetirizine to be slightly sleepy. He had the front deck tell the parents to keep the child home from school for the next few days. The mother decided to take the child to a specialist because she was concerned about the level of sedation. On the second opinion, a review of current medications was performed. It was noted that the child was taking a cetirizine tablet 10 mg two times a day, which is higher than typically recommended. A review of the error was performed at the clinic. It was noted that there was a typographical error in the instructions given to the parents, saying 10 mg twice a day, instead of 5 mg twice a day, which was the dose the physician intended.
Review the 24 analysis questions from the Joint Commission Framework for Root Cause Analysis and Corrective Actions to identity potential root causes of errors highlighted in this case.
1. Were there any steps in the process that did not occur as intended?
2. Was staff properly qualified and currently competent for their responsibilities?
3. How did actual staffing compare with ideal level?
114
Powered by FlippingBook