As you have examined in this course, errors and mishaps, although not frequent, do occur in health services organizations. While the aim is to deliver effective and quality care, errors due to systems processes or inefficient system checks still exist. As a current or future health care administration leader, applying process tools to analyze and determine the causes of such errors will likely impact initiatives aimed at fostering health care quality and safety.
For this Assignment, review the resources for this week that are specific to RCA. Reflect on the AHRQ article regarding factors that may lead to latent error and the New York Times article regarding the doctor who removed the wrong limb from a patient. Think about recommendations you might make to prevent errors such as these from occurring in your health services organization.
The Assignment: (3–4 pages)
- Briefly summarize the salient facts of the New York Times article.
- Using the AHRQ table regarding factors that may lead to latent error, assess how each factor might have contributed to the wrong-limb surgery.
- Qualitatively assess how much each factor contributed to the error.
- Provide recommendations that you believe would present such an event from occurring again, and explain why you made these recommendations. Be specific and provide examples.
RESOURCES
Ross, T. K. (2014). Health care quality management: Tools and applications. San Francisco, CA: Jossey-Bass.
- Chapter 5, “Root Cause Analysis” (pp. 161–216)
Agency for Healthcare Research and Quality. (2014). Root cause analysis. Retrieved from
Associated Press. (1995, September 17). Doctor who cut off wrong leg is defended by colleagues. The New York Times. Retrieved from
Wu, A. W., Lipshutz, A. K. M., & Pronovost, P. J. (2008). Effectiveness and efficiency of root cause analysis in medicine. Journal of the American Medical Association, 299(6), 685–687.
Note: Retrieved from the Walden Library databases.
Expert Solution Preview
Introduction:
As a healthcare administration leader, it is essential to develop strategies that work towards preventing errors and mishaps in healthcare organizations. The aim is to deliver effective and quality care, with the implementation of process tools to analyze and determine the causes of such errors. This assignment focuses on reviewing the resources for the week, including an AHRQ article regarding factors that may lead to latent error, and a New York Times article regarding a doctor’s surgery mistake. The aim is to make recommendations to prevent such errors from occurring in the future.
1. Briefly summarize the salient facts of the New York Times article.
The New York Times article discusses a medical error that occurred when a surgeon removed the wrong leg of a patient. The article mentioned that the surgeon relied on the patient’s medical records, which had mistakenly marked the wrong leg. The surgery took place despite the efforts of the nursing staff to stop the procedure. The patient underwent the surgery again, where the correct leg was removed. The incident led to a national debate on the quality of healthcare delivery, medical negligence, and malpractice lawsuits.
2. Using the AHRQ table regarding factors that may lead to latent error, assess how each factor might have contributed to the wrong-limb surgery.
The AHRQ table highlights several factors that may lead to latent errors, including communication failures, staffing patterns, and inadequate policies and procedures. These factors could have contributed to the wrong limb surgery in several ways. For example, miscommunication between the doctor and nursing staff led to the surgery taking place despite attempts to stop it. Staffing patterns and inadequate policies and procedures could have contributed to the incorrect labeling of the patient’s medical records, leading to the surgery on the wrong leg.
3. Qualitatively assess how much each factor contributed to the error.
Each factor mentioned in the AHRQ table could have played a role in contributing to the error, but the miscommunication between the doctor and nursing staff played a vital role. It led to the surgery taking place despite efforts to stop it, indicating a breakdown in communication and a lack of effective communication policies and procedures.
4. Provide recommendations that you believe would prevent such an event from occurring again, and explain why you made these recommendations. Be specific and provide examples.
To prevent such an event from happening again, the healthcare organization needs to focus on improving communication channels between doctors and nursing staff. Policies and procedures should be in place for effective communication, including protocols for reviewing and verifying patient information before surgery. Medical records should be easily accessible and clearly marked to prevent any confusion. Simple and effective checks and balances can also be put in place to cross-check the patient’s name, age, sex, and the surgical limb before executing surgery. Additionally, the implementation of technologies such as barcode scanning or Radio Frequency Identification (RFID) would also help reduce the likelihood of such errors.
Conclusion:
The incident of the medical error in removing the wrong leg from a patient underscores the importance of preventing such errors in healthcare organizations. Effective communication between doctors and nursing staff, clear and easily accessible medical records, and simple checks and balances with the aid of technology can help prevent similar events from taking place in the future. As healthcare administration leaders, it is our responsibility to implement strategies that aim to improve the quality and safety of healthcare delivery.
