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.
(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
Expert Solution Preview
Introduction:
Health services organizations aim to provide quality and effective care. However, the occurrence of errors due to system processes or inefficient system checks is still common. As a health care administration leader, it is essential to apply process tools to analyze and determine the causes of such errors to foster healthcare quality and safety. In this assignment, we will review RCA resources, reflect on the AHRQ article and New York Times article, assess how each factor might have contributed to the wrong-limb surgery, provide recommendations to avoid such events, and explain why we made these recommendations.
Question 1:
Briefly summarize the salient facts of the New York Times article.
Answer:
The New York Times article discussed a surgeon who performed surgery on a patient’s wrong limb. The patient’s name was Willie King, who was a diabetic and overweight. Due to his condition, his right leg was amputated below the knee, and he was scheduled to have his left leg amputated above the knee. The surgeon, however, removed the right leg above the knee, which was the healthy leg. The surgery was performed at a hospital in Augusta, Georgia. Despite having an informed consent agreement, Mr. King and his family found the surgeon’s mistake unacceptable, and they sued the hospital and the surgeon for malpractice.
Question 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. Qualitatively assess how much each factor contributed to the error.
Answer:
The AHRQ table lists eight factors that may lead to latent errors. These factors include task-related, organization-related, and equipment/process-related factors. Assessing each factor’s contribution to the wrong-limb surgery:
1. Task-related factors include inadequate training. In this case, the surgeon, who was responsible for the procedure, might have been undertrained in the procedure or over-reliant on assistants without verifying the patient’s information (such as confirming the correct leg to be amputated). The factor’s contribution to the error is considerable.
2. Organization-related factors include the absence of protocols and policies. The surgery required verification of the correct leg to be amputated with the patient and the entire care team. The hospital’s policies might not require the team to double-check the correct limb, which contributed significantly to the error.
3. Equipment/process-related factors include faulty instrument design, which was not relevant in this case.
Thus, the task-related and organization-related factors significantly contributed to the wrong-limb surgery.
Question 3:
Provide recommendations that you believe would prevent errors such as these from occurring again, and explain why you made these recommendations. Be specific and provide examples.
Answer:
To avoid such catastrophic events, the following are some recommendations that hospitals can consider implementing:
1. Surgeons should verify with the patient and the care team regarding any medications, allergies, or medical conditions before the surgery.
2. Hospitals should implement a standardized verification process to double-check the correct limb before performing the surgery. This will ensure that the error of removing the wrong limb is avoided. For example, using a surgical safety checklist enhances communication and collaboration among the team members and helps identify potential errors.
3. Hospitals should provide regular and ongoing training and education to the care team, especially the surgeons. This would enable mandatory training before scheduling any surgeries and periodic refresher sessions to remain informed about new procedures or device and equipment updates.
4. Hospitals should develop policies and procedures that mandate the identification and treatment of potential errors. This would ensure that appropriate policies are in place to identify errors and processes that prevent errors from repeating.
These recommendations would effectively prevent and mitigate potential errors and enhance patient safety. Hospitals across the United States should take initiative to provide quality patient care and safety by implementing strategies to ensure tasks and processes are managed and performed correctly.
