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Prairie Regional Medical System: A Case Study

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Prairie Regional Medical System: A Case Study
Felix is a 68- year old man who was admitted to an inpatient post operative care unit at Prairie Regional Medical Center (PRMC) after undergoing a laparotomy for the diagnosis of peptic ulcer. The surgical procedure went well, with no obvious difficulties. Felix’s medical history was significant for diabetes, and a hearing impairment for which he wears bilateral hearing aids. Renee is a highly regarded registered nurse (RN) who has worked at PRMC for 8-years. She and her husband have 3 children. To offset the cost of childcare for the financially strapped family, Renee and her husband work opposite schedules. She worked 12-hour shifts, 5 days off and 5 days on. Renee’s former manager agreed to the unconventional work pattern 3 years ago, …show more content…
She recalls not following proper procedure for taking a tympanic temperature. Instead of taking his hearing aids out and waiting 10 minutes, she took Felix’s temperature with his hearing aids still in his ears. Wanting to be transparent, she went to Pam and admitted what happened. Transparency is one of the IOM’s (2001) principles for redesigning the health system. According to Castel et al., (2015), one of the reasons that nurses hide errors is because they fear disciplinary action from supervisors and are concerned that errors will be logged in their personnel file, limiting career advancement opportunities. Pam had already started an investigation into how the infection had been missed. The case study claims that the inquiry revealed that the elevated temperature should have been discovered on day 3, during Renee’s shift. It is here that one of the ten principles for guiding redesign is not follow. The IOM (2001) asks safety to be viewed from a systems perspective. Pam looked at the most obvious issue, the active failure and ignored all of the latent issues, including her own
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