IHP 315_Final.docx - IHP 315 – Case Study B Southern New...

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IHP 315 – Case Study B Southern New Hampshire University
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Root Cause Analysis Timeline Paul who is 22 years old was seen immediately at the ER following a sport incident due to shortness of breath and was diagnosed with a right lower-lobe pneumothorax after it was confirmed via a chest radiograph. The attending physician instructed the nurse to perform a thoracotomy insertion on his affected right side however, the nurse performed the procedure on the opposite side which did not help in any way Paul’s shortness of breath. The nurse had then informed the physician of her error, filed an incident report and the physician had informed Paul
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of the sentinel event. At this point the physician wanted to admit Paul as an inpatient so the tube reinsertion can be done in the operating room however, no beds were available so now Paul needed to be transported to another hospital Jefferson Memorial which was 5 minutes away. The physician had coordinated transport and logistics to the new surgeon over at Jefferson Memorial and submitted a STAT transport request as the ambulance was on standby. Both the nurse and physician had a new emergency case to deal with and the unit secretary was not informed of the STAT request once she returned from her lunch break. During the delay of the transport request being carried out Paul’s oxygenation status continued to decompensate until he lost consciousness. Once the secretary noticed the order she clarified with the nurse and the nurse had gone to reassess Paul, unfortunately, he had expired. Factors In the case of Paul, he unfortunately sustained injuries while under clinical care and eventually expired as a result. Communication is key and one of the most valuable tools in ensuring optimal patient care. Some of the contributing factors in this case that caused medical error, injury and death were lack of patient verification. Being able to verify the correct patient by using at least 2 types of identifiers, correct procedure and correct site would minimize or eliminate any errors (Joint Commission, n.d). Another contributing factor was communication or the lack thereof, both the physician and nurse did not follow through with communication of the patient’s delicate and urgent condition in regard to the required STAT hospital transfer, this also includes the lack of required consent prior to performing a procedure from the patient. A sharp-end error is identified when the nurse performed the chest tube insertion on the wrong side and failed to perform a time out nor obtained patient consent. One blunt-end error that can be further modified would be the urgency when a STAT transfer request is put in, how
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can we alert the required team members in the emergency department such as the unit secretary in Paul’s case.
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  • Summer '18
  • Hospital accreditation, Patient safety, Patient Safety and Quality Improvement Act

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