Error along with the Delivery of Patient Care - Case Study Example

Investigative Interviewing Given the following data, as the leader of the in-house team tasked with investigating the situation, the essay aims to develop relevant questions to determine the causes of the incident and to summarize the findings based on the investigative interview: Henry was a 30 year old construction worker in apparently good health until he suffered a fall in his work. He was taken by ambulance to a busy, urban emergency room, was "triaged", initially evaluated by a resident physician, and placed in a cubical to await services. In the interim, the emergency room was inundated by casualties from a high rise fire. Every emergency room physician and nurse was occupied for several hours. Meanwhile, Henry waited in his cubical in terrible pain. Finally, a new resident came to check on Henry. Henrys fiancee begged that he be given something for the pain. The resident briefly glanced at the chart and ordered a shot of Demerol. Shortly after the painkiller was administered, Henry went into cardiac arrest and died. On examination, the initial intake information clearly indicated "severe allergic reaction to Demerol, morphine, and related medications. Investigative Interviewing An overview of the case facts revealed that an error occurred somewhere along the delivery of patient care. As the leader of the in-house investigative team, one has the supreme responsibility to exercise objectivity and professionalism during the investigative interview process. In this regard, the essay aims to develop relevant questions to determine the series of causes of the incident and to summarize the findings based on an effective and nonjudgmental investigative interview. Initially, the discourse would define crucial terms which would be used throughout the essay prior to a presentation of the working hypothesis or plan of action of the interview. The questions that need to be addressed would be identified and explained in terms of their relative importance to determine the causes of the unfortunate incident. Finally, a summary of findings would be proffered as an outcome of the investigative process. Definition of Terms The facts indicated that Henry, a 30 year old construction worker, was rushed in an extremely busy urban emergency room, due to a fall in his workplace. In the process of addressing the appropriate intervention, Henry’s fiancée begged that a pain reliever be given for Henry, who was in terrible pain. A new resident, briefly glanced at the patient’s chart, ordered for a shot of Demerol, of which, Henry is severely allergic to. As a result, Henry went on cardiac arrest and subsequently died. Obviously, there were some series of errors that occurred along the patient care process. The initial step is to clarify the terms that are to be used in the essay. An error is defined by the Institute of Medicine as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim” (QuIC, n.d., par.3). In the case, the error was clearly qualified when the administration of Demerol failed to improve the condition of the patient and actually contributed to his demise. QuIC decided to expand the definition of an error to encompass errors in medical practice, to wit: “an error is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Errors can include problems in practice, products, procedures, and systems” (QuIC, n.d., par.4). Since one is tasked to undertake in investigative interview, Savidge (1993) indicated that “the role of the investigative interview is to obtain accurate and reliable information from suspects, witnesses or victims in order to discover the truth about the matter under investigation” (2). As such, there are three crucial elements that must be present the process of conducting the investigative interview: (1) “the use of open-ended questions; (2) an appropriate use of silence; and (3) a lack of interruptions” (Savidge, n.d., 6). Finally, since the investigation seeks to determine mitigating circumstances, in the process, the terms is therefore legally defined as “conditions or happenings which do not excuse or justify criminal conduct, but are considered out of mercy or fairness in deciding the degree of the offense the prosecutor charges or influence reduction of the penalty upon conviction” (Hill & Hill, par. 1). Working Hypothesis or Plan of Action From the case facts, there are potential loopholes that need to be answered and reference persons who need to be interviewed. From here, the persons and questions that need to be answered would be identified to verify and validate causes of errors. The investigative process, after clarifying relevant terms, need to indicate the standard process that health care professionals should basically adhere to prior to the administration of any medications to patients. Loopholes in Case Scenario 1. Triage system At the start, from the system of sorting patients, an investigation needs to be conducted regarding the sorting and classification system used by the emergency room. As indicated by MC Strategies, “to ensure patient safety and quality outcomes, hospitals must be certain that every patient who presents to the emergency department (ED) receives the right care from the right provider at the right time — every time” (par. 1). The points that need to be clarified are: (1) Who is the main person responsible for the triage? It was mentioned that Henry was initially evaluated by a resident physician, and placed in a cubical to await services. (2) Was the resident physician authorized to classify or categorize Henry’s predicament in the first place? (3) Was Henry placed in the right cubicle? (4) Is there a standard time to address patients of Henry’s category? Why was he made to wait for several hours without addressing his needs? (5) Who is the person responsible and accountable in the triage and in the emergency room? 2. Attendant Physician’s Responsibilities Henry was assessed by two resident physicians. It was noted in his patient chart that he has “severe allergic reaction to Demerol, morphine, and related medications”. With apparent shifts in schedule, the new resident only glanced briefly in the chart causing him to order a medication of which Henry was severely allergic to. The points that need to be examined are: For the first resident physician who attended to Henry: (1) what is the standard operating procedure (SOP) for residents assigned in the ER? (2) What immediate interventions should have been given upon assessment? (3) Why did it take a long time before he was seen again, despite the number of emergency cases? For the part of Dr. Paulo Cortez: (1) From what province in the Philippines did he come from? How come he spoke with a heavy Spanish accent when Filipino is the native language in the Philippines? (2) How come there was failure on his part to closely review the information provided in the chart? What is the SOP for resident physicians in assessing patients at the ER? (3) What was his medical basis for prescribing Demerol? What dosage did he initially prescribe? (4) Does he have the capacity to prescribe narcotic and highly restricted drugs? (5) Did he explain the proposed medication to the patient or his fiancee? (6) Did he monitor the effects of the drug after administration to the patient? 3. Nurses’ Responsibilities There was no mention on the nurse’s responsibilities prior to the administration of the medication. In this regard, the following questions need to be addressed: (1) Who administered the drug to Henry? (2) What are the nursing protocols prior to drug administration? (3) What follow-ups or monitoring schemes were applied by the nurses after the drug administration? 4. Patient and Relatives’ Responsibilities Given that there have been several instances of negligence from the triage, resident physician, and the nurses during the whole process and prior to the drug administration, there is still a crucial element regarding accountabilities and responsibilities of the patients and his or her relatives or companions. In this case, Henry or his fiancée could verify the medication that is to be administered to him prior to the administration – to double check and validate that no drugs of which Henry is severely allergic to would be given. Therefore, the questions that must be asked to Henry’s fiancée are: (1) Did you verify the kind of medicine that would be given for the pain? (2) Were you able to observe any difficulty of breathing or any side effects from the drug that was administered? (3) How come the preliminary adverse effects of the drugs were not immediately reported? Standard Process Illustration for Medication Administration Think Reliability has designed a standard process illustration of the medication administration process, as shown below: Source: Think Reliability, 2010. Summary of Findings The incident clearly indicated several inefficiencies and negligence in the delivery of patient care resulting to the death of the patient. Though investigative interview, one would determine the reasons for the shortcomings and the whole process and system must be reviewed and evaluated to address the weaknesses. In this regard, the urban emergency facility must redesign their triage system to clearly indicate roles and responsibilities, as well as proper accountabilities in well defined tasks. There are several check points which could have prevented the administration of the wrong drug. Aside from the primary responsibility of the attending physician’s negligence in the administration of the drug, the mitigating circumstances were the triage system and protocols, the nurse’s failure to refer back to the chart and to ask or advise the patient of the medication being administered, and the failure of either the patient and the relative (or fiancée) to double check the drug that was to be administered – as well as immediate reporting of drastic effects of the drug. Point persons must double check the tasks undertaken by their predecessors to avoid continuing an identified error. References Hill, G. & Hill, K. (2005). Mitigating Circumstances. Retrieved 27 November 2010. < http://legal-dictionary.thefreedictionary.com/mitigating+circumstances> MC Strategies.(n.d.). Emergency Nursing Triage. Retrieved 27 November 2010. < http://www.mcstrategies.com/mosbynursingnews/htmlemail02/pdf/ED-nurse-triage02.pdf> Quality Interagency Coordination (QuIC) Task Force. (n.d.). Chapter 1: Understanding Medical Errors. Retrieved 27 November 2010. < http://www.quic.gov/report/mederr4.htm> Savidge, N. (1993). Investigative Interviewing. Retrieved 27 November 2010. < http://www.adb.org/Documents/Events/2008/9th-Conf-International-Investigators/Nigel-Savidge-presentation.pdf> Think Reliability. (2010). Medication Errors and Medical Facilities. Retrieved 27 November 2010. < http://www.thinkreliability.com/hc-medicationerror.aspx> Read More