What was the event?

What was the event?

What was the event? 150 150 Nyagu

Continuous Quality Improvement in Health Care Essays
Continuous Quality Improvement in Health Care Essays

Read Exhibit 9-1(below) on Continuous Quality Improvement in Health Care. You are in charge of the risk management team that must investigate this incident and report to the CEO of the hospital. Based on what you have learned, list all the system failures that contributed to the patient safety event and discuss the following:

What was the event?
Who was involved?
Was there a process in place that might not have been followed that contributed or caused this event to take place?
Describe the project that you would assign to your quality improvement team to complete to prevent this from happening again.
Describe the project that you would assign to the health information management team to complete to prevent this from happening again.

Your response must be at least 2 pages in length of Continuous Quality Improvement in Health Care Essays and include complete sentences and complete paragraphs in APA format.
You may submit numbered lists, when appropriate.
References must be cited using APA format.
EXHIBIT 9–1 Patient Safety Scenario—Interview with a Third-Year Pediatrics Resident

Resident: I had a patient who was very ill. We thought that an abdominal CT would be helpful and it needed to be infused. He was 12 years old and was completely healthy up until 3 months ago and since then has been in our hospital and two other hospitals, pretty much the entire time. He has been in respiratory failure, he’s had mechanical ventilation (including oscillation), he’s been in renal failure, he’s had a number of ministrokes, and when I came on service he was having diarrhea—3 to 5 liters/day—and we still didn’t know what was going on with him.

He was a very anxious child. Understandably, it’s hard for the nurses, and for me, and for his mother to deal with. He thought of it as pain, but it was anxiety and it responded well to anxiolytics.

When I came in that morning, it hadn’t been passed along to nursing that he was supposed to go to CT that morning. I heard the charge nurse getting the report from the night nurse. I said, “You know that he is supposed to go for a CT today.” She was already upset because they were very short staffed. She heard me and then said that she was not only the charge nurse, but also taking care of two patients, and one had to go to CT. She went off to the main unit to talk to someone. Then she paged me and said, “If you want this child to have a scan, you have to go with him.” I said, “OK.” Nurses are the ones who usually go. But it didn’t seem to be beyond my abilities … at the time.

So, I took the child for his CT and his mom came with us. We gave him extra Ativan on the way there, because whenever he had a procedure he was extra anxious. When we got there, they weren’t ready. We had lost our spot from the morning. My patient got more and more anxious and was actually yelling at the techs, “Hurry up!” We went into the room. He was about 5 or 6 hours late for his study and we had given him contrast enterally. The techs were concerned that he didn’t have enough anymore and wanted to give him more through his G-tube. I said, “That sounds fine.” And they mixed it up and gave it to me to give through his G-tube. I went to his side and—not registering that it was his central line—I unhooked his central line, not only taking off the cap but unhooking something, and I pushed 70 cc of the gastrografin in. As soon as I had finished the second syringe I realized I was using the wrong tube. I said, “Oh no!” Mom was right there and said, “What?” I said, “I put the stuff in the wrong tube. He looks OK. I’ll be right back, I have to call somebody.”

I clamped him off and I called my attending and the radiologist. My attending said that he was on his way down. The radiologist was over by the time I had hung up the phone. My patient was stable the whole time. We figured out what was in the gastro-grafin that could potentially cause harm. We decided to cancel the study…. I sent the gastrografin—the extra stuff in the tubes—for a culture just in case he grew some kind of infection and then we would be able to treat it and match it with what I had pushed into the line. I filled out an incident report. I called my chiefs and told them…. They said, “It’s OK. He’s fine, right?” I said, “Yes.” They came up later in the evening just to be supportive. They said, “It’s OK. It’s OK to make a mistake.”

Interviewer: What was your attending’s response?

Resident: The attending that I had called when I made the mistake said, “I’m sorry that you were in that situation. You shouldn’t have been put in that situation.” Another attending the next day was telling people, “Well, you know what happened yesterday,” as if it were the only thing going on for this patient.

I thought it was embarrassing that he was just passing on this little tidbit of information as if it would explain everything that was going on. As opposed to saying, “Yes, an error was made, it is something that we are taking into account.” And he told me to pay more attention to the patient. Yes, I made the mistake, but hands-down I still and always did know that patient better than he did. I just thought that was mean and not fair. And the only other thing I thought was not good was the next morning when I was prerounding some of the nurses were whispering and I just assumed that was what they were whispering about. I walked up to them and said, “I’m the one who did it. I made a mistake. How is he doing?” I tried to answer any questions they had and move on.

Interviewer: How did the nurses respond when you said that you made a mistake?

Resident: The nurse that had sent me down with him told me, “It’s OK, don’t worry about it.” The others just listened politely and didn’t say anything.

Interviewer: How did the mother respond to you the next day?

Resident: The next day, I felt really bad. I felt very incompetent. I was feeling very awkward being the leader of this child’s care—because I am still at a loss for his diagnosis. And after the event, when the grandma found out—she was very angry. I apologized to the mom and I thought it would be overdoing it to keep saying, “I am so sorry.” So, the next day I went into the room and said to the mom, “You need to have confidence in the person taking care of your son. If my mistake undermines that at all, you don’t have to have me as your son’s doctor and I can arrange it so that you can have whoever you want.” She said, “No. No, it’s fine. We want you as his doctor.” Then we just moved on with the care plan. That felt good. And that felt appropriate.

I couldn’t just walk into the room and act like nothing had happened. I needed her to give me the power to be their doctor. So, I just went and asked for it.

(Sollecito 259-260)

Continuous Quality Improvement in Health Care Essays

Sollecito, William A. McLaughlin and Kaluzny’s Continuous Quality Improvement In Health Care, 4th Edition. Jones & Bartlett Learning, 20110929. VitalBook file.