Case study 2
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School
California State University, Stanislaus *
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Course
4300
Subject
Health Science
Date
Feb 20, 2024
Type
Pages
3
Uploaded by ElderExploration12951
Case Study Ch. 7
"Communication of Patient Information"
, pg. 549 - 550.
1. What are the facts of this case?
-
Margaret Burns is a 63 year old woman who has been in the hospital and been transferred
to a skilled nursing facility for strengthening prior to returning home to live
independently. While at the skilled facility she develops pain, swelling in her right leg as
well as a fever. An ultrasound is performed where a DVT is found. Margaret is prepared
to be transferred back to an acute care hospital for treatment; however her paperwork gets
mixed up with other patients and she is given the incorrect medications and ends up in the
ICU.
2. Review the quality improvement tools in Ch 7 and select the appropriate one to analyze this
problem.
-
Root Cause Analysis (RCA) is a systematic process used to identify the underlying
causes of an adverse event, error, or problem in healthcare. It is a structured approach that
helps organizations and healthcare teams understand why an issue occurred and develop
strategies to prevent its recurrence. RCA involves several steps, including:
●
Define the Problem: Clearly articulate the problem or adverse event, which in this
case is the administration of the wrong medications to Margaret Burns, resulting
in the extension of her hemorrhagic stroke.
●
Collect Data: Gather all relevant information and data related to the incident,
including the timeline of events, communication processes, documentation, and
personnel involved.
-
By applying RCA to this case, healthcare organizations can gain insights into the
systemic issues that led to the medication error and work on implementing corrective and
preventive actions to prevent similar incidents in the future. Additionally, it promotes
transparency and accountability in healthcare processes, which is crucial for patient
safety.
3. What are the top three management issues in this case?
-
The protocol was not followed for double checking the orders to ensure they were the
correct orders for Mrs. Burns prior to her leaving the building. The hospital did not make
sure that they had received the correct orders prior to administering medication to Mrs.
Burns. The last issue is that Carole is rushing to get her job done because of personal
issues. The staff needs to make sure that they are not rushing and are paying attention to
what they are doing.
4. What are the legal and ethical obligations a health care organization has to its patients and
families and how do they apply to this case?
-
The ethical rights, on the other hand, are viewed as a voluntary and private act of a
person depending on their conception of good and evil. Medical malpractice, informed
consent, and confidentiality are the three key legal challenges that affect the healthcare
system.
5. Who should be held responsible for addressing these problems?
-
Healthcare Organization Leadership: The leadership of both the skilled nursing facility
and the acute care hospital should be responsible for addressing systemic issues related to
communication, protocols, and staffing that contributed to this error.
-
Frontline Staff: The secretary, who handled the patient records, bears some responsibility
for not following established protocols and verifying the correctness of the records.
6. Which healthcare facility is responsible for the medication errors? What obligations does the
facility have to Margaret? To her family?
-
Both the skilled nursing and rehabilitation facility and the acute care hospital share
responsibility for the medication errors. The skilled nursing facility is responsible for
providing accurate patient information during transitions, and the acute care hospital
should have verified the records upon Margaret's admission.
-
Obligations to Margaret: Both facilities have an obligation to ensure Margaret's safety,
well-being, and appropriate treatment. This includes timely and accurate communication
of her medical history, medications, and conditions.
-
Obligations to Her Family: The facilities have an obligation to communicate
transparently with Margaret's family about the errors, the resulting complications, and the
steps being taken to address the situation. They should also involve the family in
decision-making regarding Margaret's care.
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