Michael’s Case Study on Medical Errors Essay
Michael’s Case Study on Medical Errors Essay
-RNBS 4631 Nursing Leadership& Management
Clinical Activity -Quality &Safety Scenario
Name: _____________________________ Date: ________________
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Refer to reading material and resources found in Module 2 and Module 5. This clinical will take several hours to complete, so start reviewing this activity soon.
Read the case situation and answer the questions in complete sentences and describe fully. Answer the questions as specifically as possible. Each section can expand as needed.
Submit your completed template (do not alter this template) in Canvas by the due date/time. Please type directly on this template.
Please proofread all your work before submitting. Michael’s Case Study on Medical Errors Essay
Synthesize clinical knowledge for planning and evaluating complex care priorities.
Critique nursing care examples for holistic care elements including teaching and advocacy.
Propose nurse leader strategies for incorporating cultural aspects of care.
Rank healthcare delivery strategies according to advantages or disadvantages for the nurse manager and for the staff nurse.
Evaluate legal and ethical aspects of quality assurance and risk management.
Contribute ideas for implementing a service philosophy to positively affect nurse-consumer relationships.
Evaluate cost issues in healthcare delivery and ethical implications of financial decisions that affect delivery of effective patient care.
Evaluate strategies for maximizing the nurse leader’s and manager’s actions in effective team building including conflict management.
Recommend strategies to promote professional accountability in nursing leadership and management roles.
Evaluate nursing leader and manager actions according to laws and standards of Texas Board of Nursing, and ANA Code of Ethics.
Show reflective evidence of increasing role awareness in holistic caring practice.
Evaluate available research evidence for best practice.
Rate effectiveness of interventions to prevent safety risks and provide safe environments.
Critique legal and ethical actions of nurse leaders and managers aimed at providing safe patient care.
Evaluate nurse leader and manager strategies for providing confidential and secure patient care technology. Michael’s Case Study on Medical Errors Essay
Michael, a 16-year-old Hispanic male, is admitted to Hospital XYZ on Monday, for removal of a painful bone growth on his left dorsal foot. He began complaining of pain after playing soccer on several occasions. During his admission to the surgery unit, his mother states he is generally healthy except for mild heart condition and asthma. She states, “His doctor is checking is heart every six months and will eventually need surgery.” Michael’s EHR indicates he has amild mitral valve prolapse with faint murmur present since birth and asthma for which he uses Symbicort (budesonide/formoterol) inhaler BID and a rescue inhaler as needed. The holding RN prepares Michael for his day surgery procedure, completes his assessment (all parameters WDL – within determined limits), 0.9% NS IV is started @ a rate of 50 ml/hr. His armband is checked for proper identification, the operative consent is signed byMichael’s mother indicating surgery is to be performed on the left foot. The CRNA interviews Michael and looks over the admission information documented by the RN and asks if he has any allergies – the response is “no allergies.”Due to Michaels’ cardiac history and asthma, the plan is to admit him overnight for continued observation and follow up. Pre-operative and prophylactic medications are given to Michael in the surgical prep area. Anticipated discharge will be Tuesday evening. Michael’s Case Study on Medical Errors Essay
Ten minutes before surgery is to begin, the surgeon runs into the room stating, “I am running behind…traffic was horrible on the way here. I apologize for getting here so late.Let’s get you marked. We are doing the left foot right?” Michael says,“yes sir.” The surgeon marks the right foot and pulls the cover back over Michael’s foot then says, “See you in the OR in 5 minutes – this will not take long.”The surgeon then shakes Mom’s hand, explains that they will call with updates, and leaves hurriedly. Michael’s mother looks worried and hesitates to say anything more and sits back down.
The circulating RN comes in to get Michael – she looks to see if the operative consent is signed, sees Mom’s signature and says, “We are good to go kiddo – your surgeon did mark your foot right?” Again, Michael says “yes.” Michael is taken to the OR where the CRNA is ready with anesthetics drawn up and immediately begins the sedation process. The circulating RN notes the “X” on the right foot and proceeds to prep the right foot. When the surgeon arrives after scrubbing in, the circulating RN goes to the computer to run through the hospital’s approved “time out” checklist and complete the required “time out” protocol. The surgeon says abruptly, “I personally marked his foot – it is correct so we don’t need to do this, we are all here and ready to get this done. We are already way behind schedule for the day.” The circulating RN reluctantly rechecks the patients’ armband to verify he was the correct patient and went on with the procedure. Michael’s Case Study on Medical Errors Essay
Fifteen minutes into the case the surgeon comments that he does not see nor can he feel the bony abnormality indicated on the xray – the circulating RN checks the operative consent once again and discovers that they have opened up the wrong foot. The surgeon quickly decides to close the right foot and proceed to the left foot.
As the surgeon is finishing the correct surgical site (left foot), he asks the CRNA to begin “lightening him up” and to administer Ancef (cefazolin) 1 gm IVPB to cover any risk of wound infection and provide prophylaxis for his mitral valve prolapse. The CRNA reaches back into the top drawer of his anesthesia cart for the antibiotic, pulls the drug out then dilutes the vial with 10cc’s normal saline and injects it into a 50ml bag 0.9% NS and hangs it running wide open. The CRNA administers the appropriate reversal agents to awaken the patient, but Michael does not wake up as anticipated. Upon checking the empty vials on the top of the anesthesia cart they discover the patient had been given Ketamine (ketalar) in error. The MD chief anesthesiologist is summoned and an investigation begins related to the errors in the OR. Michael’s Case Study on Medical Errors Essay
Michael’s parents were informed about surgery on the wrong foot without explanation as to how/why this happened. They were informed about the need for prolonged ventilation due to a medication error, but again were not given the details other than “we paralyzed his lungs and he may have problems breathing due to his asthma for a few days and will need follow up.” When questioned about the medication error by the anesthesia team and risk manager, he commented, “The Ancef (cefazolin) has always been in the back left box, top drawer in the anesthesia cart – I didn’t look at the label on the vial. Someone put the medication in the wrong drawer.”
In this case TWO major medical errors occurred. The errors were wrong site surgery and a medication error. The hospital decides to conduct a root cause analysis (RCA) into the human factors and process failures involved. Michael’s Case Study on Medical Errors Essay
Section 1:(45 Points this section)
YOU are the Risk Manager (RN) responsible for conducting a root cause analysis on this case. You are new to the facility and do not know the current/specific procedures being followed for marking the surgical site or filling the anesthesia carts.Your investigation begins.
Determine WHO (staff titles) should be present for the RCA. List all attendees for this RCA. (This includes all staff present and all managers, directors, etc.)(5 points)
Make a list of detailed questions that you feel are appropriate to ask during the exploratory phase of the RCA regarding wrong site surgery. (questions regarding wrong site surgery)(5 points)
Make a list of detailed questions that you feel are appropriate to during the exploratory phase of the RCAregarding administration of wrong medication. (questions regarding administration of wrong medication)Michael’s Case Study on Medical Errors Essay. (5 points)
Determine what PROCESSES of care that potentially failed for both errors based on what you know.Think about cultural implications as well. Describe these in detail. (5 points)
Wrong site surgery:
What other data would you want to collect during this investigation? Describe in detail. (5 points)
Examine the fishbone diagram to identify the potential “root causes” in this situation. (Use the Yoder-Wisetext book pg. 419, 424). Use the diagram below as you think about the possible causes for these errors. You may add more items as needed. Describe each section (you do not have to draw or mark on the fishbone diagram). (10 points)Describe the possible root causes below.
Root Causes for the Wrong Site Surgery:
Root Causes for the Medication Error:
If this case ends up in litigation, could there bevicarious liability? If so, who would be liable for damages? Explain your rationale. (5 points)
What potential issues could arise with reimbursement/insurance for the patient/family, additional costs to the hospital due to the errors? Added LOS (length of stay)? Explain your rationale. (5 points)Michael’s Case Study on Medical Errors Essay
Section 2: (10pointsthis section)
YOU are the Quality Director/Safety Coordinator for the hospital and work closely with the Risk Manager. In preparation for the RCA you are asked to do the following:
Look up best practice “surgical time outs” or “safe surgery checklist” for more detail. This also referred to as “The Universal Protocol through The Joint Commission (TJC). Give the reference of where you found this. Make sure that your source is credible as a best practice. Where did the process fail in this scenario? Describe. (5 points)
Look up both medications from this scenario and review implications for administration, rate, dose etc. Explain your rationale. (5 points)
Six rights of medication administration: List them here.
Where did the system fail? Where did the CRNA fail?
Section 3:(40points this section)
YOU are looking at the scenario from the surgeon, the CRNA, and the family perspectives.
As the surgeon and CRNA, what would you say to the family?How much detail should be disclosed, in what format, why?When and how would you discuss these errors with the family? Explain your rationale.(5 points)
Write a brief script of what the physician would say to the parents of Michael. (5 points)
Is it appropriate to apologize the family? Why or why not? Explain your rationale. (5 points)
What ethical principles are involved? Please list at least 3 ethical principles that are related this case. Explain the ethical principle and give your rationale. (5 points)
Ethical dilemma #1:
Ethical dilemma #2:
Ethical dilemma #3: Michael’s Case Study on Medical Errors Essay
Look at the data – – look up Parkland, UT Southwest, and Baylor (on Gaston Ave)? Look up each hospital on medicare.gov/hospitalcompare. Answer the following questions: (15 points)
Criteria Parkland Health & Hospital System, 5200 Harry Hines Blvd., 75235 UT Southwestern University Hospital – Zale Lipshy, 5151 Harry Hines Blvd., 75390 Baylor University Medical Center, 3500 Gaston Ave, 75246
Overall star rating: What is the star rating? What does this mean?
Review data on Survey of patients’ experiences. Are there any assumptions you can make? Review the patient survey questions and relay any important findings. Review % for each agency and compare to Texas Average and National Average.
Look at the “Complications and Deaths” tab across the top. Review the information on Surgical Complications – Serious complications. What did you learn from each hospital?
Look at the “Unplanned Hospital Visits” tab and watch the short YouTube video.
Review examples of unplanned readmissions by medical condition and procedure.
1. Who measures how many days or extra days patients stay in the hospital?
2. List 3 examples of unplanned readmissions and hospital return days by medical condition.
3. List 3 examples of unplanned readmission and hospital visits by procedure.
If you knew this comparative data before the procedure, would you have used this facility?Explain your rationale. (5 points)
How could the OR team work together to prevent this issue from happening again? What is TeamSTEPPS? How can this program assist teams to work more effectively together? (Look this up on the internet and give a brief summary of what TeamSTEPPS is and how it can assist organizations.) (5 points)
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There are various hospital staffs that should be present for the root cause analysis in the said medical error case study. These includes the hospitals certified registered nurse anesthetists, medical director chief anesthesiologists, pharmacists, circulating registered nurse, hospital’s health records specialist/representative, three nurses who are more often in-charge of the surgical areas, the hospital’s surgeon and a representative of the hospital’s administrator. The need for each of these healthcare personnel during the root cause analysis of the identified case study varies from one to another. For instance, the hospital’s pharmacists is crucial in the said root causes analysis process, to help in identifying whether the wrong labeling of the medications, is an ongoing issue within the hospital, and its possibility of resulting to the said medication error to the presenting patients.
Although this role may seem associating with the medical direction chief anesthesiologist, considering it was an issue in the anesthesia cart, proper medication labeling may be a prevailing situation in the entire hospital, thus calling for the need to involved the hospital’s pharmacists in the root cause analysis process. On the other hand, the inclusion of the three more often nurses in-charge of the surgical area would be essential at determining the occurrence’s frequency of such medication errors during surgeries, when the in-charge nurses are informed and are present. Michael’s Case Study on Medical Errors Essay
Some of the crucial questions that I will ask during the exploratory phase of the root cause analysis on the wrong site surgery includes
What are the possible causes for the surgeon labeling the wrong surgical site?
Was negligence the main reason(s) for the circulating registered nurse failing to counter-check the labeled surgical site prior to the surgery’s onset?
Is such reluctance of rechecking the patient’s armband prior to the surgery, a common scenario within the hospital and among the circulating registered nurses?
Do the circulating registered nurses get a lot of authorization pressure from the surgeon, resulting to them forgoing certain procedures?
Does negative workplace culture result to the occurrence of the said wrong site surgery error? Explain your answer when offering examples.
Does this wrong site surgery error illustrate any shortcomings within the hospital’s electronic health records? If yes, how and which?
What are the possible applicable but effective practices/strategies for solving such wrong site surgery relative errors in the future within the hospital?
Some of the crucial questions that I will ask during the exploratory phase of the root cause analysis on the administration of the wrong medication includes
What are the main factors that led to the administration of the wrong medication to the presenting patient-Michael? Michael’s Case Study on Medical Errors Essay
Are there possibilities of such administration of the wrong medication to patients cut across the entire hospital? If yes, explain.
Can the administration of the wrong medication to Michael as the contextual case patient relates to the shortcomings of the hospital’s pharmaceutical department?
Between the hospital’s head of pharmacy, certified registered nurses anesthesia and medical director chief anesthesiologist, who do you think is the solely responsible to the said administration of wrong medication? Give reasons to support your answer.
What can be done to curb the occurrence of such wrong medication instances in the future, within the hospital, in all its departments, not only in the surgical area?
Failed processes of Care
Wrong site surgery
The processes of care that potentially failed resulting to the rise of the wrong site surgery includes inefficient communication and the circulating registered nurse reluctance/ negligence of verifying the patient’s information with the electronic health records and lack of following the laid medical procedures in the surgical area. The case scenario reveals inefficient communication between the surgical team, and to the patient. For instance, Michael’s mother notices a mistake in the marking of her son’s intended surgical foot, although the surgeon’s hurry impedes proper communication resulting to the mother failing to express her concern on the wrong labeling of her son’s surgical foot. The circulating registered nurse is reluctant and neglects adhering to the laid medical procedures in the surgical area such as verifying whether the presenting patient is the correct one or not, through using the electronic health records, before proceeding with any other procedure. It is during the verification process that the circulating registered nurse would have identified wrong labeling of the patient’s intended surgical foot.
Some of the failed processes of care associating with the said administration of wrong medication includes wrong drug’s packaging, labeling and placement. The medical director chief anesthesiologist argues on Ancef being on the left box of the top drawer in the anesthesia cart, unlike Ketamine, which indicates wrong placement of the medication. In addition, the negligence of the certified registered nurse anesthesia in reading through the medication box is the other failed care process that resulted to the occurrence of the said medication error. Healthcare personnel are required to read through the medication’s packaging box, thus verifying the appropriateness and validity of the medication, prior to administering it to any patient, especially the unconscious ones. Michael’s Case Study on Medical Errors Essay
Other data that I would collect during the contextual investigation is the unreported medication errors, complication incidences arising from surgical operations and the frequency of the nurses, the surgical and anesthesia team neglecting the laid medical and surgical procedures. Data on unreported medication errors would reveal if there has been the occurrence of such similar errors in the same surgical area, but went unreported. Data on complication incidences arising from the surgical operations would help in identifying the occurrence frequency of such errors within the hospital’s surgical operations. The last set of data on the frequency of the involved healthcare personnel neglecting the procedures would help to determine the intensity of negligence behavior among the personnel. Such would reveal whether or not the healthcare personnel rarely or frequently engage in know negligence of certain procedures, and their relative possible causes.
Root cause analyses
In case the case ends up in litigation , there is a great possibility that there could be vicarious liability, especially on the hospital’s administrators such as the medical director chief anesthesiologist. Vicarious liability refers to the instance where the senior are responsible for the unlawful actions of their juniors. In this case, the MD chief anesthesiologist would be responsible for the administration of the wrong medication by the certified registered nurse anesthesia to the patient- Michael. A case in the litigation would clearly determine the occurrence of the said medication errors, arising from the wrong labeling, packaging and placement of the Ketamine at Ancef’s box of the hospital’s anesthesia cart drawer. The litigation would offer a vicarious liability to the MD chief anesthesiologist since on questioning, he confessed he did not look the label and made the assumption of its placement, when placing the blame on someone else putting the medication in the wrong drawer.
Some of the potential issues which could arise with the reimbursement for the patient family such as delayed or prolonged reimbursement due to several reasons such as lack of a solid and capable insurance within the hospital, or prolonged litigation processes. More so, the hospital maybe reluctant at participating in the entire process, which would slow down the reimbursement. Michael’s Case Study on Medical Errors Essay
There are certain additional costs to the hospital that may arise from the occurrence of the errors such as recruitment of full-time hospital based surgeon, installation of monitoring devices like the closed-circuit television, suspension of certain involved health personnel in the medication errors. All these would result to the hospital incurring additional expenses. For instance, the risk manager would require the hospital to recruit another full-time hospital based surgeon to reduce unnecessary hurriedness, which was a possible cause for the wrong labeling of the surgical site patient’s foot. The hospital would thus be required to increase its salary expenditure.
Just like the hospital, the patient’s family would also incur additional medical expense prior to reimbursement. The additional medical expense would arise from prolonged stay at the hospital, in an effort to get effective treatment for reversing the effects of the medication errors.
The best practice for surgical time outs and surgical safety checklist requires the surgical team to brief, sign-in, timeout, sign-out and debriefing. The Joint Commission Board requires all the entire surgical team to immediately pause prior to the surgery to confirm the correct patient, involved procedures and site. One of the best practices for surgical time outs is where they are done prior to the start of the surgical procedure, and should actively involve the entire surgical team (Berlinger & Dietz, 2016). Another best practice for surgical time outs is where there is 100% visible and oral agreement of entire surgical team, after the time out statement, with the statement including patient identity (Berlinger & Dietz, 2016).
However, the case study surgical operation failed in various instances in their surgical time outs. For instance, the circulating registered nurse runs to the computer and completes the “time out” roll outs, which eliminates the involvement of other members of the involved surgical team. More so, the circulating registered nurse does not call out the time outs statement which including patient’s identity. Also, there lacks active involvement and 100 visible and oral agreement of the entire surgical team, which manifests through the involved surgeon dismisses the need for the surgical time outs. Michael’s Case Study on Medical Errors Essay
Cefazolin is an antibiotic, which is more often used either before or during surgeries to prevent infections. Administered in pediatric patients through injection, with documented hypersensitivity contraindications, with possible side effects such as seizure, nausea and vomiting. Ancef –cefazolin- is efficient for the case study patient, especially considering Michael was undergoing surgical operations. The medication would help in preventing him acquire any infections.
Ketamine (Ketalar) is an anesthetic medication, which is more often use for either starting or maintaining anesthesia. The medication relates to certain contraindications, making it inappropriate for surgical procedures involving skeletal muscle relaxation. With such, the medication was not effective for the contextual patient, since Michael was undergoing a foot surgical operation, which involved skeletal muscle relaxation. More so, the medication is only appropriate for short surgical procedures and not longer procedures like Michael’s surgical foot.
The six rights of medication administration includes
The right patient
The right medication
The right dose
The right route
The right time
The right documentation.
The system failed in ensuring that the above said six rights of medication administration relating to the patient were not followed, resulting to a hitch in the identification of patient thus subjecting Michael to the wrong surgical operation. The Certified Registered Nurse Anesthesia failed in the administration of the wrong medication to the involved patient. The Nurse administered ketalar, for a different intended purpose- reversal agent for awakening the patient. Ketalar has adverse effects on Michael, the patient, resulting to his prolonged unconsciousness. Michael’s Case Study on Medical Errors Essay
As the surgeon and Certified Registered Nurse Anesthesia, i would only let the family know their patient had certain complications, without mentioning the details of the exact scenario. However, I would concentrate so much on reassuring the family that their patient is in safe hands and the surgical team is working towards ensuring the patient recovers safely. When offering such reassurance, I would desist from offering the exact time for the patient’s recover, but would use words such as “your patient will recover very soon”.
All the information need to be disclosed to the family, although such would happens and follow an order based on the severity of the patient’s case. If the patient is not in severe case, the only information that should be disclosed is that their patient encountered certain complications. However, if the medical and surgical team intervention does not work immediately, the surgical team can request some of their members to explain the complications, and its possible causes. It is of great need to disclose the information in this ascending order based on the severity of the patient’s condition, to prevent the family overreacting on the medical errors and safeguard any possible suing of the hospital and surgical team by the patient’s family.
It would only be effective to discuss the involved medication errors with the patient’s family whenever the patient condition becomes severe, or if the patient recovers but with certain complications. In both of these instances, there is the need to inform the patient’s family on the occurrence of the medication errors, as an explanation of the possible cause for the patient’s developing the complications. There are various ways of discussing these medication errors, although the most appropriate and effective one would be arranging a detailed sitting with the family, and involve other crucial parties such as hospital psychiatrist and counselor. The inclusion of the counselor would help in counseling the patient’s family, for they are likely to develop certain wild psychological and behaviors such as depression, stress and anger. Michael’s Case Study on Medical Errors Essay
A brief script of the physician’s speech to Michael’s parents would be
“ Hope you are doing well Mr. and Mrs. Jason. We are glad that you choose us to treat and conduct a surgical operation on your child, and we are committed to ensuring he gets the best services and recovers well. However, as you well know, surgeries are bond to encounter certain hitches, which may result to certain complications. The presence of complications does not mean the patient has lost their life. Just like any other patient, I’m sorry to share with you that Michael encountered certain complications, and I can assure that our able team is working to help him recover. Kindly bear with us, and have patience as we provide the best care to your patient. Thanks for giving me your time and ear. If you have any question, let me know and I will address. “
It is appropriate to apologize with the family, and that should also involve sympathizing. Doing so would assure the family that the surgical team and hospital are concerned about the well-being of their patient. It also offers the family an assurance that the medical errors were un-intended, and thus happened without the consent and knowledge of the surgical team. As a result, the family is likely to understand the situation (although it is not guaranteed), and may not place any blame towards the surgical team and hospital thus refraining from suing either of the two. Therefore, apologizing with the family doesn’t not only assure them about their patient’s condition, but also reduces the chances of the hospital and surgical team being sued by the patient’s family.
Berlinger, N., & Dietz, E. (2016). Time-out: the professional and organizational ethics of speaking up in the OR. AMA journal of ethics, 18(9), 925-932. Michael’s Case Study on Medical Errors Essay