Error Analysis and Recommendations

Twenty-year-old student developed a right-sided pneumothorax while playing soccer. He had no prior remarkable medical history. A chest film confirmed a right lower-lobe pneumothorax. The doctor ordered a thoracotomy insertion tray as soon as the equipment was provided at the bedside, the nurse inserted the chest tube into Paul’s left side. As time was of the essence, no consent was signed and a time out, usually performed in surgery, was also not done. Following the chest tube insertion, there was no improvement in Paul’s shortness of breath. At this time, the nurse informed the physician that the chest tube had been inserted on the wrong side.The nurse noted in Paul’s record that an incident report was filed for the wrong-side insertion, following the doctor’s written order to do so. The emergency physician attempted to have Paul admitted as an inpatient to Union Hospital so that the reinsertion could be done in the operating room. The nursing supervisor informed the physician that there were no available inpatient beds at Union and Paul would need to be transported and admitted to Jefferson Memorial, five minutes away. As an ambulance was on standby at Union, the physician ordered immediate transport and also communicated with the surgeon at Jefferson about Paul’s condition. The unit secretary had just returned from taking a late lunch break and did not see the transfer order. The nurse was admitting another patient to the emergency department. Paul oxygenation status continued to decompensate and he lost consciousness. At 1430, the secretary noticed the order and clarified with the nurse. When the nurse went to reassess Paul, he had expired. The physician has professional liability insurance as a condition of his employment at Union. The nurse does not. Final Paper Requirements: A. Details: Based on state and federal reporting requirements and the results of the root cause analysis(RCA), identify the details that would be necessary to disclose the error to the patient and family. B. Method and Preparation: How would you suggest disclosing these details to the patient and family? What preparation would be needed for the staff, patient, and family before the disclosure? C. Reporting: What elements of the RCA and corrective action plan (strategies) would need to be shared with accrediting or regulatory agencies? For example, what elements should be reported to the State Department of Health and Human Services? What should be reported to The Joint Commission? IV. Patient Safety Culture: In this section, you will analyze patient safety culture through the use of a survey as an assessment tool. Specifically, you should address the following: A. Analysis: Analyze all of the patient safety culture survey results at the facility where the error occurred. These results are embedded in your B. Outcome: In what ways might the outcome have been different if the facility had a stronger patient safety culture? Your response should be based on your analysis of the patient safety culture survey. C. Recommendation: Recommend one method that could be used to improve the patient safety culture. Justify your recommendation with your analysis of the survey. V. Communication: In this section, you will propose communication and teamwork strategies, explaining how these strategies promote safer patient care. Specifically, you should address the following: A. Strategy: What strategies could be used to improve communication and team building? Explain why you selected the strategies, basing your response on your analysis of the medical error and the patient safety culture. B. Safer Patient Care: How does the strategy strategies promote safer patient care? What evidence do you have to support your response C. Measurement: How will the communication and teamwork strategy or strategies be measured? In other words, how will we know that communication improve

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