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Reply to each discussion. Each reply Should be 450 words, included 2 sources, and 1 biblical integration pertaining to each subject.
Discussion 1: Imagine going into the hospital for a routine procedure, fully trusting your physician and healthcare team, then waking up missing a limb or having to go back under anesthesia at a later date for the procedure you were supposed to have done in the first place. This can cause a number of complications for patients in regard to money, time from work, self consciousness concerning appearance, anxiety related to hospitalization, and not to mention it places a barrier between the patient and provider regarding a relationship.
How do medication errors occur in the first place? One might think it is the lack of judgment or laziness of the provider and/or care giver. However, a number of factors to consider when medical malpractice is a concern. Nwosu states there are many risk factors to keep in mind when evaluating cases of malpractice, such as, distraction factors, incomplete preoperative assessments, lack of availability of pertinent information, and policy issues regarding surgical site verification in the operating room (2015). The solution to preventing wrong-site, wrong-procedure, wrong-person surgeries recommended by the Joint Commission is to complete the minimum requirement of preoperative verification, mark the incision site, and initiate a “time out” prior to procedure start. In doing so, studies have found a 50% reduction in Wrong-site surgeries since mandating this process, not to mention there have also been improved patient outcomes regarding decreased surgical complications and increased detection of possible safety concerns (Nwosu, 2015). If the act of following these simple tasks prior to procedure start improves health outcomes as well as prevents the unnecessary harm of a patient I agree they should be strictly enforced.
Communication is key to preventing sentinel events such as these. The Joint Commission defines a sentinel event as any patient safety event that causes death, permanent harm, or severe temporary harm that requires existential measure to sustain life. These types of patient safety events should be investigated immediately and thoroughly via root cause analysis, to prevent further harm (Nelson,2017). As we have previously discussed, in 2004 the Joint Commission created the Universal Protocol for Preventing Wrong-site, Wrong-procedure, Wrong-person Surgery by implementing the preoperative verification, site-marking and time out requirements prior to procedure start. In 2009 the World Health Organization came up with a surgical safety checklist which consists of three phases designed to remind providers to adhere to specific safety protocols (Nelson, 2017).
The time out is the final check prior to incision. Traditional time out sessions verify the correct patient, procedure, site, and allergies. However, Nelson proposes an enhanced time out be initiated by including verbal participation by the circulating nurse, lead surgeon who initiates the time out, and anesthesiologist for all elements covered in the traditional time out. The surgeon is not allowed to begin until all of the requirements of the enhanced time out have been completed and the circulating nurse documents the process in the electronic health record in real-time. Documentation should include the names of all providers involved in the enhanced time out (2017).
Documentation is key to patient safety and prevention of provider liability. Nursing documentation initiates the visit following registration. Topics such as history, vital signs, medications, and treatment records are some of the data collected during a patient’s stay by nursing staff. Physician documentation is much more complex and includes topics such as history and physical, procedure notes, orders, progress notes, consultation reports, and a discharge summary describing what happened during the patient’s hospitalization (Shanholtzer & Ozanich, 2016).
Paul teaches us to look ahead and learn from our mistakes when he says, “Not that I have already grasped it all or have already become perfect, but I press on if I may also take hold of that for which I was even taken hold of by Christ Jesus. Brothers and sisters, I do not regard myself as having taken hold of it yet; but one thing I do: forgetting what lies behind and reaching forward to what lies ahead, I press on toward the goal for the prize of the upward call of God in Christ Jesus” (The Holy Bible; NASB, 2020, Philippians 3:12-14). In the instance where I myself have made a mistake, regardless of the severity, it sticks with me. I remember how guilty I felt and how joyous I was not to have caused significant harm. We must do this in our Christian walk as well as in our careers, forgetting the past mistakes and reach forward for what our true potential can be.
Nelson, Patricia E., MSN-Ed, RN, CNOR. (2017). Enhanced time out: An improved communication process. AORN journal, 105(6), 564-570. https://doi.org/10.1016/j.aorn.2017.03.014
Nwosu, A. (2015). The horror of wrong-site surgery continues: report of two cases in a regional trauma centre in nigeria. Patient safety in surgery, 9(6). https://doi.org/10.1186/s13037-014-0053-2
Shanholtzer, M. B., & Ozanich, G. W. (2016). Health information management and technology. McGraw-Hill Education.
The holy bible; NASB. (2020). The Lockman Foundation.
Discussion 2: We all understand that human error occurs within virtually every field of business. However, when errors occur in the health care industry, lives could be at stake in addition to major malpractice lawsuits. Surprisingly, even with modernize technology errors still occur in the health field, starting with the registration department. One human error in the registration process can follow that patient all the way through their hospital stay or procedure. Then imagine that one error leading to more and more errors throughout the patient’s health journey. While there are some ways to prevent numerous errors within the health system, there are also a lot of error that slip through the cracks (Tena et al., 2018). Especially when it comes to administering incorrect medication and/or dosages. The development of electronic health portals, records, and documentation is a huge accomplishment for the American health system, but we must keep in mind that human errors still occur, and we can’t solely rely on electronic means to catch incorrect information.
The case report that will be summarized for this post is regarding two cases of surgery that were performed on the wrong site following a road traffic accident. Furthermore, the report discusses how there were no formal hospital policies that could have prevented these cases of wrong site surgery. As I discussed in my intro for this discussion, medical errors are common within the health care industry and there are numerous cases like the one discussed in this case study, that still happen all over the world. The first case discusses how a 75-year-old woman visited the hospital in Nigeria during the year 2011, she had been in an accident and was unable to bear weight on her left leg. After further examination by two doctors and a radiology report it was determined that the patient needed hip surgery, which ended up being performed on the wrong side due to multiple different mentions of right vs left in both doctor’s notes. The radiology report showed a right hip dislocation and fracture, however, the doctors performed the surgery on the left hip. On a subsequent radiology report, it was determined that the wrong site was operated on, and the patient was taken back to surgery two days later (Nwosu, 2015).
The second case resulted in a 43-year-old bus driver who presented to the hospital in 2012 due to an inability to bear weight on both lower limbs following a traffic accident. Radiological information was provided that there was fractures in both femurs in addition to a left lower leg fracture. The patient went into surgery and the right hip surgery was started, the doctor then made a cut to the lower right leg and was notified by the anesthesiologist that this lower leg operation was being done on the wrong site (Nwosu, 2015). Hospitals really need to make sure that they have protocols in place to handle wrong site surgeries when they do happen and furthermore, find a way to reduce the number of wrong site surgeries that happen. I know that when I have had surgeries, the doctor usually comes in the pre-op room and puts an “x” on the surgery site. Thus, helping to reduce the occurrence of wrong site surgery in some capacity.
Incorrect or missing data in electronic health records is one of the top 10 patient safety concerns identified in a recent report (Cohen et al., 2019). Inaccurate registration information can harm patients and registration errors are common in the healthcare industry. Some of the most common mistakes cause duplicate and overlay records. One example would be misspelling the name of a patient in the master patient index. A registrar could also mistakenly enter data for one patient into another record for a patient with the same name. Registration accuracy is a very significant issue in terms of patient safety. Every piece of data collected at the point of entry is used by other hospital staff, clinical and non-clinical, throughout the patient’s stay. Hospital leadership should make registration staff are aware of how they have an impact on patient care; making sure that they understand that the information they obtain affects the patient’s care, long after they are no longer in contact with the patient.
John 1:8 “If we say that we do not have any sin, we are deceiving ourselves and we’re not being truthful to ourselves.” I felt that this was a good scriipture for this week as it discusses how God wants us to handle our own mistakes by making sure we are truthful with ourselves when mistakes do occur. This is pivotal to the health care industry as human errors do happen, it is important for all individuals to acknowledge their mistakes, correct them, alert the proper leadership and move forward.
Cohen, R., Ning, S., Yan, M. T. S., & Callum, J. (2019). Transfusion safety: The nature and outcomes of errors in patient registration. Transfusion Medicine Reviews, 33(2), 78-83. https://doi.org/10.1016/j.tmrv.2018.11.004 (Links to an external site.)
Easterling. (2021). Healthcare Informatics (1st ed.). New York, NY: McGraw Hill.
Nwosu, A. (2015). The horror of wrong-site surgery continues: Report of two cases in a regional trauma centre in nigeria. Patient Safety in Surgery, 9(1), 6-6. https://doi.org/10.1186/s13037-014-0053-2 (Links to an external site.)
Tena, R., League, S., & Brennan, J. (2018). Preventing wrong site, wrong procedure, wrong patient errors. Nursing made Incredibly Easy!, 16(3), 10 13. https://doi.org/10.1097/01.NME.0000531884.39767.8f
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