Patient Safety/Quality Care/Improvement Case Study
Patient Safety/Quality Care/Improvement Case Study
1. Overview of what are medical errors and possible consequences of such errors?
The Institute of Medicine (IOM) defines medical errors as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.” Medical errors do not all result in harm or injury. Medical errors that cause injury or harm are sometimes called preventable adverse events – that is the injury is thought to be due to a medical intervention, not an underlying patient condition. Errors resulting in serious injury or death are considered “sentinel events” by the Joint Commission. These signal need for immediate response and analysis to identify all factors contributing to the error and reporting to the appropriate individuals and organizations to implement or guide system improvements.
The types of error or harm are further classified regarding domain, or where they occurred across the spectrum of healthcare providers and settings. Agency for Healthcare Research and Quality (AHRQ) research has shown that errors can occur at any point in the health care delivery system. Medical errors most frequently result from systems errors—organization of health care delivery and how resources are provided in the delivery system.
2. What type of error occurred in the case study and where was the breakdown in communication?
In this case study a medical error occurred because Dr. Summer’s nurse and the G.I. Lab failed to identify and confirm the Right Patient when scheduling a lab exam. A series of communication errors and lack of appropriate follow-up communication occurred in this case study. Dr. Summer’s nurse did not have the G.I. Lab scheduler verbally confirm both the patient’s and physician’s names - only the prescribed tests were confirmed by the nurse and scheduler during their phone conversation. There was also no confirmation of the scheduled procedure and appointment sent or communicated by the facility
1. Overview of what are medical errors and possible consequences of such errors?
The Institute of Medicine (IOM) defines medical errors as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.” Medical errors do not all result in harm or injury. Medical errors that cause injury or harm are sometimes called preventable adverse events – that is the injury is thought to be due to a medical intervention, not an underlying patient condition. Errors resulting in serious injury or death are considered “sentinel events” by the Joint Commission. These signal need for immediate response and analysis to identify all factors contributing to the error and reporting to the appropriate individuals and organizations to implement or guide system improvements.
The types of error or harm are further classified regarding domain, or where they occurred across the spectrum of healthcare providers and settings. Agency for Healthcare Research and Quality (AHRQ) research has shown that errors can occur at any point in the health care delivery system. Medical errors most frequently result from systems errors—organization of health care delivery and how resources are provided in the delivery system.
2. What type of error occurred in the case study and where was the breakdown in communication?
In this case study a medical error occurred because Dr. Summer’s nurse and the G.I. Lab failed to identify and confirm the Right Patient when scheduling a lab exam. A series of communication errors and lack of appropriate follow-up communication occurred in this case study. Dr. Summer’s nurse did not have the G.I. Lab scheduler verbally confirm both the patient’s and physician’s names - only the prescribed tests were confirmed by the nurse and scheduler during their phone conversation. There was also no confirmation of the scheduled procedure and appointment sent or communicated by the facility