1-3 case study - The wrong patient PDF

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1-3 Case Study: Single- Event Analysis – The Wong Patient

IHP-430 Healthcare Quality Management Date: 01/17/2021 Ins: Southern New Hampshire University Name: Jacquayle Tate 1-3 Case Study: Single – Event Analysis – The Wrong Patient

1-3 Case Study: Single – Event Analysis – The Wrong Patient

1-3 Case Study: Single- Event Analysis – The Wong Patient

This Case study describes the events that led up to the wrong patient undergoing an electrophysiology procedure that were not intended for scheduled for them. These events began with two patients that were admitted to that hospital with similar names, and similar record numbers. The case study focuses on two patients named Joan Morris and Jane Morrison, in which patient Morris was mistaken for Morrison. Patient Joan Morris was transported to electrophysiology for an oncology procedure (Ross,2014) . Multiple errors were overlooked indicating that the patient Morris was the wrong patient, over 17 active errors contributed to the patient's mistaken identity (Ross,2014). Although patient consent was granted, the patient questioned the procedure as if she did not want to undergo the procedure. The importance of the missed protocols was a failure to follow proper protocols to identify patient and ensure that patient understands and consents to the procedure. The Systematically faulty exchange of information amount doctors and nurses and poorly ignored physical safeguards to minimize staff workload. The role of data collection and data analysis in measuring the chronology is significant to allow wellbeing frameworks. Data collection and analysis helps to collect measurements to customize treatment plans, advance treatment strategies, improve correspondence among specialists and patients, and upgrade wellbeing results. The importance of data collection is a cycle by which information are assembled and estimated, it is through this cycle that administration has the quality data they need to settle on educated choices from the additional investigation, study, and exploration. Exact information assortment is basic to keeping up the respectability of patient profile and outlined directions for their right use to diminish the probability of errors occurring.

1-3 Case Study: Single- Event Analysis – The Wong Patient

A proper data collection measure is essential as it guarantees that the information assembled is both characterized and precise that the resulting choices dependent on the contention epitomized in the discoveries are substantial. The process gives both a benchmark from which to quantify and in specific cases a sign of what to improve that helps sequentially by taking a contextual investigation of a specific individual to evade misidentification for treatment methods (Nolan,2000). It is imperative to recognize two gatherings of these variables. Ecological variables are not promptly alterable, in any event in the short run, and in this manner, they structure the fixed substance where frameworks and individuals work. It is vital to understand and examine the patient and why she is hospitalized and effectively arrange arranged tests and treatments. They act synergistically to increase the probability that the wrong patient will undergo an invasive procedure. The proper steps that should have been taken in this cause would actively communicate as a team and to indicate the protocols to identify the patient. Multiple physicians, residents, and nurses failed to communicate with each other in a variety of departments throughout the hospital. The staff failed to listen to the concerns of the patients, the patient was confused regarding the procedure and was hesitant regarding undergoing the procedure he importance of data collection is a cycle by which information is assembled and estimated, it is through this cycle that the administration has the quality data they need to settle on educated choices from the additional investigation, study, and exploration. Exact information assortment is basic to keeping up the respectability of patient profile and outlined directions for their right use to diminish the probability of errors occurring. Human errors are predictable and can be prevented by following the correct protocols by using all the safety initiatives to prevent mistakes. Therefore, all

1-3 Case Study: Single- Event Analysis – The Wong Patient

healthcare systems should indicate the importance of effective communication, teamwork, and safety protocols. We are all human and errors are to be expected, therefore mistakes are the common theory of human behavior. The approach of the theory is learning from your mistake and understanding how to prevent future errors (Sherman, 2014). Errors can occur rather you strategize stages of a task because human error is part of the ordinary spectrum of life. Precautions that can be used in this case study are to follow the Quality health services standards and requirements to identify and confirming patients. Identifying the patient by asking the patient to confirm their demographics to ensure that it is identical to medical records or orders.

Patient

procedure protocol gives direction concerning the means that should become taken to accurately coordinate patients to their expected consideration and the hospital policies and procedures.

1-3 Case Study: Single- Event Analysis – The Wong Patient

Reference Page: Ross, T. K. (2014). Health care quality management: Tools and applications. Somerset, NJ: John Wiley & Sons, Inc. Nolan, T. (2000). System Changes to improve Patient Safety: PMC. US National Library of Medicine. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117771/ Sherman, J. (2014). Why We Make Mistakes. Retrieved from https://www.psychologytoday.com/us/blog/ambigamy/201409/why-we-make-mistakes...