Start by providing a short 4-6-line synopsis of the key elements of the case – and discuss what kind of incident occurred (week 1). In this case, “Medical error kills Hopkins Cancer Patient” by Erika Niedowski, the error was the failure of a planned action to be completed or intended and the use of a wrong plan for instance overdosage of potassium to achieve an aim. These errors were preventable and may not have caused the harm. Preventable adverse drug events and their causes and contributing factors had caused stopped Brianna Cohen's heart. Hence, this is a sentimental event because this unanticipated event resulted in death to a patient, not related to the natural source of the patient's illness. Therefore, the threat and error management model should be used to determine both training needs and organizational strategies to improve the management of threats to safety. What defenses in the system failed in this case? Can you construct a Swiss cheese analysis of the system defenses and what occurred? In this case, the James Reason’s “Swiss cheese” analysis illustrates the …show more content…
After surgery, radiation, chemotherapy and a marrow transplant, an improperly mixed intravenous solution apparently stopped Brianna Cohen's heart. Hence, this case shows that there is an unintended act either of commission or omission, does not achieve its intended outcome, failure of a planned action to be completed for instance an error of education which was the mixed solution, potassium, which caused the heart rhythm to regulate. Furthermore, there was a wrong plan to achieve an error like an error of planning and deviation from the process of care. Therefore, receiving the incorrect medication, or missing a diagnosis that is evident on a lab test or imaging study is a medical
Liability Issues Primarily, Caring Memorial Hospital will be held liable in this malpractice case under the premise of respondeat superior. “Under respondeat superior an employer is liable for the negligent act or omission of any employee acting within the course and scope of his employment” (Thornton, 2010, para. 2). The risk manager Susan Post, JD and the quality assurance director Amy Green were both aware of the potential for increased risk on the Oncology unit. They had been making observations several months prior to incident that related to deficiencies in staffing and safety standards. Per, ASCO and ONS (2012) new staff are required to demonstrate competency and receive comprehensive chemotherapy education.
In this situation there are key ethical and legal situations that arise from the treatment and transportation of Craig. As the police are now involved the paramedics have better assistance with the legal side of restraint however the ethical issues remain import and need to be managed correctly. The first issue raised is the physical restraint of the patient, even thought the police are present the paramedics could take a different approach to avoid the use of physical restraint. It could be argued that the physical restrain is necessary in this situation as the patient could be a danger to himself or others.
- Safety provi¬sions are interpreted to protect patients from illnesses caused in the course of medical treatment as well as to provide hygienic and injury-free experience in the health care setting. Special provisions exist for safety in pharmaceuticals, blood supply, infectious disease treatment and diagnostics, and mental health services, among others. Ethical codes for doctors, nurses, and other health care workers contain provisions applicable to the patients’ right to safety. Medical errors and other actions that fail to meet safety standards can carry civil, criminal and administrative penalties
Paradise Hill Medical Center – Case analysis 1. Recognize the background: the key of this step is to understand the medical issues involved. The medical issue in the Paradise Hill Medical Center (PHMC) was that 22 oncology patients received excessive doses of radiation therapy. The patients have not been informed yet that they received and overdose of radiation. The CEO alleged that it was the responsibility of the medical staff to inform the affected patients, and the medical team decided not to inform them about the error.
1. Introduction including a brief & factual review of the medical error or sentinel event. (References used to depict the source of information obtained.) a. Anesthesia Awareness is devastating as well as putting a toll on anyone’s life.
YES! People make mistakes,its called being human. Men are given the nature of human,because there is a reason god is called the almighty. Since no man is perfect in this world ,it is evident that a person who is skilled and has knowledge over a particular subject can also commit mistakes during his practice.
In many cases of negligence bad practice takes in place that are intentional for someone’s financial gain, but in other cases it could be the lack of communication. Many patients face misdiagnosis and treatment from their nurses or doctors and it leads into an unintentional commission. 34- year- old Kim Tutt was healthy and doctors informed her that she had three to six months to live due to jaw cancer. Tutt went ahead with the surgery to get the cancer removed from the left side of her chin to behind her right ear and replaced it with the fibula from her leg. She has children of the ages 10 and 12 years old and wanted to spend as much time that she could in their lives.
There were specific situations that led to the cause of Julie Thao's actions of medication error and the death of Jasmine. The situation could have completely been avoided had Julie followed the code of ethics and avoided shorts to provide proper care for the patient. The state claimed that Thao's mistake was caused by actions, omissions and unapproved shortcuts, however, there were other factors that played a role in her carelessness as well. While failure to comply with procedure has been a factor in the medication administration error, other factors contributed as well. For example, failure to properly use the information system, or to ignore alerts or warnings have also resulted in preventable errors (Nelson, Evan, & Gardener, 2005).
Failing in service-user safety can sometimes be attributed to communication failure, however communication is one of the most important tools in preventing such failures. The ability to communicate effectively as a team stems from understanding the various professions in the team (Gluyas & Morrison, 2013). Understanding the various roles allows for an insight into how the healthcare system links together and the part each roles plays in provision of care. Additionally it aides in building trust and respect amongst team members (Gluyas & Morrison, 2013). This in turn can be linked to improved service-user safety, because it allows for role relation and see their part in the service-user care pathway.
Medication errors can be very dangerous for the ones taking the wrong medicines or doses; therefore, safety measures must be in place. Administering them must be done with an understanding and focus. One missed check could have a staff member giving a resident the wrong set of pills. Some interventions to help prevent the medication error from occurring is to first report errors. When errors are reported, the main cause is to try and never let the error occur again.
The concern for safety has become a bigger and more important issue, and these two departments are forming a relationship. Although it has been the tradition for these two departments to work separately, they both have a common goal, to oversee the safety and excellence in healthcare organizations. Some smaller organizations have always had the same person control quality and risk and remained successful. These days, we are seeing a lot more collaborations, goal sharing, ad idea exchanging among these two groups (Perry, 2007). Risk management is critical to every organization.
Missed identification of shock symptoms in Ms. Gadner 2. IV infiltration being missed resulting in her not receiving fluid ordered 3. “Scanty documentation” depriving the physician of information on Ms. Gadner’s current condition 4. Administration of valium and morphine, contraindicated in shock, nursing not questioning the order 5. Didn’t communicate need for transfer to Dr. Dick.
“Overview of Failure Mode and Effects Analysis (FMEA): A Patient Safety Tool.” Global Journal on Quality and Safety in Healthcare 6, no. 1 (2023): 24–26. Understanding the significance of patient safety in medical treatment, describing how risk management protects patient safety quality, and employing Failure Mode and Effects Analysis to identify potential dangers and areas for immediate improvement. To assist in avoiding and reducing medical errors that cause patient damage. The authors employ risk management to help healthcare companies improve the efficacy and dependability of service quality by identifying, assessing, and establishing standards.
Consensus Summary of Yolanda Pinnelas Case Study The purpose of this paper is to discuss a case study involving a 21-year-old patient, Yolanda Pinnelas, who was studying to be a musical conductor, and who was being treated with chemotherapy. The toxic medication allegedly caused severe deformity of the patient’s hand when it seeped out of the intravenous (IV) catheter and into the surrounding tissues with minimal intervention by the hospital staff noted. This malpractice case will be reviewed thoroughly by each one of the group members and a discussion of the issues relating to duty, documentation, liability, damages and more will be discussed in detail within this paper.
Medical malpractice refers to skilled negligence by a health care professional or provider in which treatment provided was below standards, and caused damage, to a patient. In common cases, the medical malpractice or negligence involves a medical error, possibly in diagnosis, drug dosage, wellbeing management, treatment or aftercare. Examples of hospital errors include: Giving the patient the incorrect medication, Leaving possessions inside the patient 's body after surgery, Misdiagnosis, etc. (Nordqvist). According to timesofindia.indiatimes.com (Iyer) World Health Organization believes that one in 10 hospital admissions leads to an unfavourable event and one in 300 admissions in death. While a British National Health System survey in 2009