Quality Exemplar Assignment: Clinical Scenarios

A time-out is to be conducted immediately prior to performance of the procedure, it is initiated by the nurse or technologist, it involves all personnel involved in the procedure, the team members agree to a minimum of patient identity, correct site, and correct procedure to be performed, and all of this information is documented in the record, including those involved and the duration of the time-out.

B required as his health deteriorated. The LPN, however, made the error of not notifying the staff of Mr. B’s condition. She again, made the error of simply silencing the patient’s alarms and walking away. Furthermore, according to policy, Mr. B was to be provided supplemental oxygen and continuously monitored, including the use of ECG, throughout the recovery period, for which he did not have. These numerous hazards and errors eventually led to a code situation and ultimately the death of Mr. B. This death, as it turns out, was a result of a simple medication error for which the team must now implement a change to prevent similar errors from occurring again in the future.

Additionally, the care environment developed a hazard when the patient population increased both in number and acuity with the admission of the acute respiratory distress patient and increasing patient load in the lobby without note of available back up staff being called in. Examples of errors from the flow chart comparison might include failure to assess and monitor when Nurse J initiates blood pressure and SpO2 measurements, fails to initiate ECG with respiration monitoring, fails to administer supplemental O2, and leaves the room without apparently noting the baseline of the patient2. Furthermore, there appears to be an error in the lack of communication collaboration between the RN and LPN regarding Mr. B’s post procedure status and monitoring needs, and there is a failure to rescue when the LPN notes the low SpO2 value, fails to respond, and instead re-initiates another blood pressure reading without noting the results. As Mr. B’s condition deteriorates and a code is called, an ACLS error is observed in the timeline when the patient is noted first to have absent pulse and respirations and that a monitor is next applied and the patient and displays ventricular fibrillation. Chest compressions appear to not have been the first action in this scenario, nor is end tidal CO2 monitoring noted as initiated to monitor the quality of compressions. These are examples of hazards and errors in the care of Mr. B and in an actual RCA the level of detail would likely turn up

Procedure to indicate “a time-out must occur when two or more procedures are performed on the same patient and the individual performing the next procedure changes”

Lack of enough trained staff in conscious sedation available at the time of the procedure

To do so, I am going to use the fishbone diagram to categorize the causative factors (Potter & Perry, 2008).   For patient characteristics, Mr. B was a 67 year old patient with routine use of oxycodone to treat chronic pain.  Because of his routine use of oxycodone, he may need a different dose to get to a sedated level than other people who are not on any medication.  Next is the task factors, the hospital had a policy which requires that anyone who are treated with moderate sedation or analgesia have to be put on continuous blood pressure, ECG, and pulse oximeter monitoring until the procedure is done and patient is in stable condition.  Mr. B was not being monitored accordingly during the sedation process.  Another task factors is that all staffs must first complete a training module on sedation before performing the task.  Individual staff is a factor too, Nurse J had completed the training module on sedation, he had an ACLS certification as well as experience working as a critical care nurse.  Team factors include communication between staffs; an example would be the LPN not informing Nurse J or Dr. T when the alarm went off the first time, it showed that Mr. B had low oxygen saturation.  Work environment factors included the staffing in the ER, the equipments they had, and the level of experience of the staffs.  According to the scenario, additional staffs were available for back up support and all the equipment needed

The discharge criteria in the policy states the patient will be fully awake, vital signs stable, no nausea or vomiting, and the patient is able to void. All practitioners that provide moderate sedation must complete a training module prior to providing moderate sedation, this includes personnel assisting with the procedure. The first process failure was not meeting the required monitoring of the patient as mandated by the moderate sedation policy. In the absence of ECG or respiratory monitoring the sedation administered produced apnea then asystole without ED personnel being aware of acute changes in the patient’s condition. There is no explanation for why the patient was not on continuous ECG monitoring. Equipment was found to be in good working order.

Johnson was not administering anesthesia to the patients and the chief of anesthesia also failed her facility because she did not keep in mind that this was a safety violation for patients and Dr. Johnson’s coworkers.

In Mrs. Lushko's case, even though she underwent expedited inpatient evaluation, she had to consult different specialists and they asked almost the same questions which indicates that there is no seamless sharing of information/records about a patient's medical condition. Also, these specialist teams were not working as single integrated team of specialists to determine her treatment plan which is why her initial evaluation took so much time and she received conflicting opinions about removing her tumor. Mrs. Lushko was not admitted through oncology department instead of primary team. It could have eased her oncology/endocrinology evaluation tests and diagnosis during her initial evaluation. In addition, each doctor had his/her own interpretation of data instead of collaboratively working as a team to decide upon definitive treatment plan. Excellent providers will not only integrate across the value chain within their own organizations, but also with independent entities involved in the care cycle. An ideal CDVC

Unintentional errors, near-misses, and adverse patient outcomes occurring in the intensive care unit can range from significant to fatal. These errors have

UP.01.03.01 requires a time-out before the start of the procedure. The Site Identification and Verification policy describes the time-out process however the policy falls short of fully meeting the intent of this standard. EP 2 describes which team members must participate in the timeout, EP 3 requires a time-out before each procedure when two or more procedures are being performed, and EP 5 requires documentation of the time-out. These 3 elements are missing from the hospital policy/process and therefore revisions to the process/policy are necessary to include these 3 elements. Nightingale’s Safety Report reveals increasing compliance (nearing 100%) with the time-out process, however as mentioned above, EP 5 requires documentation of the process. In addition to the policy revision, I recommend the development of a unique form which will be used to document

Medical errors are avoidable mistakes in the health care. These errors can take place in any type of health care institution. Medical errors can happen during medical tests and diagnosis, administration of medications, during surgery, and even lab reports, such as the mixing of two patients’ blood samples. These errors are usually caused by the lack of communication between doctors, nurses and other staff. A medical error could cause a severe consequence to the patient in cases consisting of severe injuries or cause/effect any health conditions, and even death. According to recent studies medical errors are not the third leading cause of death in the United States. (Walerius. 2016)

When a patient misses a doctor/nurse appointment, a follow-up or specialist appointment they are not receiving the care recommended by their doctor/nurse. This could result in the patient becoming more ill and requiring additional time off work, laying an extra burden on colleagues and bosses, there is also the risk of infecting others thus carrying additional burdens as more staff may require time of work or extra appointments. All of this holds a risk of missing deadlines, looking unprofessional and potentially disrupting the training of personnel on unit.

Upon arrival a patient should have been made aware about a delay therefore he/she would not get inpatient. The appointment itself should not be rushed. A health proffessional should have explained everything in a clear and precise manner giving patient the opportunity to voice any concern or ask any additional questions. In regards to the appointment itself, the

There are times where specialists require some assistance in discovering the particular issues and states of their patients. At the point when specialists need to be certain about what their patients' conditions are, they take body liquid or tissue tests from them and forward these examples to the pathology advisors.