Factors Which Predisposed to the Errors at Various Stages of Care - Case Study Example

Running Head: Root Case Analysis Name Course Instructor Date Root Case Analysis: The Unfortunate Admission The case is about Jane Nagel is an 18-year-old woman who first presented at the emergency department (ED) complaining that she was “not feeling well.” She informed the admitting staff she had nasal congestion, stuffiness, sore throat and a cough for the last couple weeks. She also had achy joints and chest discomfort on the right side. Jane had been diagnosed with SLE (lupus) two years ago. James Hall MD, learned that she had stopped taking her Plaquenil about two months ago. A rheumatologist had seen her initially and followed her; however Jane often is unable to go to her appointments because of her lack of transportation. The only records which were available showed her last nine months appointments. In her case of being treated there were a multiple system failures, poor documentation and lack of coordination between the various attendants. This lead to poor coordination of care and communication. The inadequate technology and absence of absence of a safety culture further complicated the situation finally resulting to Jane’s death from complications of septic shock. This root cause analysis aims at analyzing the factors which predisposed to the errors which were performed at various stages of care. Jane Nagel death would have been avoided if there was proper coordination of care and effective communication between the different levels of care. The root cause analysis is designed to explain how this incidence occurred and what can be done in future to prevent its reoccurrence. People should learn from their mistakes, correct all that went wrong and prevent future mistakes from happening. Proximate causes to missed diagnosis Failure to arrange psychiatric consult The psychiatry department despite being informed of the Jane’s case and the fact that she was not on care failed to follow up on her. The psychiatry staff instead of following up on the case instead decided to give phone contacts which the Doctor was to pass to the patient. Failure to arrange social work consults Jane was a case that required serious social work follow up, she was predisposed to so many factors which would have made adherence to drugs impossible. In several occasions she has defaulted both the clinics and medication. No physician referred her for social work consultancy despite discovering the problems that she was facing. Failure of appropriate handing overs There are several situations in the case where lack of proper handing over from one staff to the other has led to misdiagnose and ultimate discharge of the patient. Failure of adequate discharge planning, where the patient was not under proper care after she was discharged. The physicians despite establishing that Jane had some social issues did not refer her to social work and mental health clinic. Possible root cause of the Jane’s death Technical causal factors The staff had not been well acquainted with the use of the Electronic Health Recording system that the hospital was using. The system itself was not complete, since only a few of Jane’s appointment were available while others could only be obtained manually from her file. Lack of training on the system made the physician to miss the lab report which would have led to proper diagnosis of Septicemia and avoid the readmission and consequent death of the patient. Human There was poor communication between the staff members. The handing over was not effectively carried out. There was complacency where the attending physicians were consulted through the phone and made decisions based on the information which they were given. The decision to discharge Jane was reached after the telephone consultation where the physician believed that the patient was okay and ready for discharge. There lacked a proper follow up system where lack of seriousness where nobody seems to be sure of Organizational causal factors There lacked a proper discharge and follow up systems. The patient was supposed to be referred for psychiatry follow and social work services given her social problems. This did not happen despite the fact that the need was identified. There lacked a system where patients who were need would be assisted, Jane reported that she missed some of her appointments due to transportation problem. When she was recalled back to the hospital when the misdiagnosis was established, the hospital would not provide a cab despite her poor health condition. She failed to report back immediately as it was required due to lack of transport. There was lack supervision especially among the interns, they were left alone to carry out their tasks leading to some errors which would have been avoided if they were properly supervised and guided.Other organization errors included poor communication handoffs, poor documentation, Evidence based interventions Various strategies can be to provide solutions to identified problems. The strategies selected should work towards reducing risks, the method chosen should be cost effective and result oriented. Effective communication in any forum is very important; it not only ensures that message is delivered timely but also clearly understood and acted upon. In this case, there is a serious breakdown in communication between the care providers; this resulted to serious errors which ultimately lead to Jane’s death. There ought to be a standardized system for taking patient history to avoid a situation where some of the details are missed. This is a mistake which was noted when the physician failed to get the information from the patient concerning her bi polar disorder. ( Burt CW, et al. 2005) (Wilson et al2005) Information sharing also need to be emphasized, there seems to be a lapse on this. This is seen when the physician failed to locate the positive laboratory results which would have helped in the proper diagnosis. A policy should be put in place to promote a culture where members of a care team view each other with respect and as equal. This is a concept where the communication flows in all the directions. This to large extent encourages all the care providers to be extra vigilant and detect any potential errors correcting them early enough and avoid serious repercussions. In such a situation interns will not be afraid of seeking help and neither will be supervisors intimidate or fail to accept their mistakes. Pepper (2006) recommends a system where the physician models their behavior through asking other care providers such as nurses and interns among others for their input and encourages teams to share information on a regular basis Culture change as a strategy need to be used to address the problems that afflict the hospital where Jane was attended. There is a need for each care provider to access practice performance. The assessment should create an environment where team members share information honestly and openly. Make it easy to learn from errors, where people would not be afraid to accept they are wrong. The environment within the hospital should allow a situation where people feel free to disclose information on errors that they may have committed during their course of providing care. More importantly a system where people can report errors should be established. The management needs to come up with a system where those who may have committed errors can be supported with education rather than punishment. System changes should be put in place to help in prevention of future errors, a mix of external and internal information has been identified as an effective in leading to a system changes which will guarantee patient safety during provision of care. (Patterson ES, Roth EM, Woods DD, et al. 2004) According to the Journal of the American Medicine Association the incidences of missed, delayed or incorrect diagnosis range in between ten to twenty percent. (Miller 2014) The journal in 2012 reported that incorrect diagnosis spans the breadth of clinical practice, right from the common disorder to rare conditions. The journal observed hat while some diagnostic errors lead to litigation a majority of errors result to no legal actions. (Miller 2014) The journal recommends that patients must become their own advocates and observe measures that make a different between life and death. Jane lacked initiative in monitoring her health. She had missed previous appointment leading to a default in her medication. If she was on follow up, her immediate problem would have been diagnosed and treated without any need for admission. Lack of her initiation from her part and failure to be the best advocate for her health led to deterioration of her health such that she went to seek care when things were already out hand. (Miller 2014) (Patterson ES, Roth EM, Woods DD, et al. 2004) Although the hospital has in place an Electronic Health Records system, there seems to be serious lapses with the system. First being new, there is a need for training all the care providers on its use. It is only through this that errors which occurred when the physician failed to retrieve the lab results would be eliminated. Information technology experts recommend use of automated and other technologies, through which physicians can easily check and track patient information, get to suggest a follow up and raise a red flag when necessary. Miller (2014) appreciates that medical records can be easily accessible but there are also cases when misdiagnosing of abnormal laboratory test. He suggests that this can be prevented from happening through having a second person who looks at the information and confirming whether anything would have been missed by the physician. (Patterson ES, Roth EM, Woods DD, et al. 2004) It has been established that Jane’s death was directly as a result of multiple system failures which led to poor coordination of care as well as lack of safety culture. The failures were identified as lack of proper follow up on the patient. It is evidently clear that the death of Jane Nagel would have been prevented if there was a proper coordination of care and supervision of the care providers. A reliable and strong electronic health system accompanied with training of the users would have made the patient information easily accessible leading to quick decision making system. (Wilson et al2005) A social support mechanism needs to be strengthened to ensure patients who do not have the capacity to make it to the hospital get to the hospital on time and get the necessary care. Improvement in the coordination of care, improved communication, culture safety and functioning systems would greatly help in improving patient safety and to a large extent avoid incorrect or delayed diagnosis. (Wilson et al2005) Reference Miller Stephen (2014) Help Employees Avoid a Costly Misdiagnosis Pepper G (2006) Do no harm: medication safety for the GNP. Program and abstracts of the National Conference of Gerontological Nurse Practitioners 25th Annual Conference Burt CW, McCaig LF, Rechtsteiner EA. (2005) Ambulatory medical care utilization estimates for 2005. Hyattsville, MD: Centers for Disease Control and Prevention; National Center for Health Statistics; 2005. Wilson KA, Burke CS, Priest HA, et al. (2005) Promoting health care safety through training high reliability teams Ch 14: 303-309. Patterson ES, Roth EM, Woods DD, et al. (2004) Handoff strategies in settings with high consequences for failure: Lessons for health care operations. Int J Quality Health Care Read More