week 4 assigment Sentinel Event
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School
Ashford University - California *
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Course
460
Subject
Medicine
Date
Feb 20, 2024
Type
Pages
11
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1 Week 4: Title of Paper
Your Name Ashford University HCA 460: Health Care Administration Capstone Instructor's Name Date
2 Title of Paper
On the 6
th
day of April in 2020, Ms. Victoria Edwards, a longtime patient at Christus Frances Hospital, underwent open heart surgery. The physician that preformed the surgery was Dr. Oscar Green and the attending physician was Dr. Howard Karr, a newly hired doctor that has been employed at Christus Frances for 2 years. During Ms. Edward’s checkup, a URFO was discovered. Reports show that the patient called Dr. Green several times to inform him that she was experiencing some discomfort prior to this appointment. However, due to COVID, many appointments were delayed. Since the discovery of the URFO, Ms. Edwards has had surgery to successfully remove the foreign object and is recovering well. There has been a full investigation into all parties involved that will be included in this report. Part 1: The Sentinel Event As mentioned earlier, Ms. Edwards had open heart surgery on the 6th of April in 2020. The two attending physicians were Dr. Green and Dr. Karr. Prior to her checkup, Ms. Edwards called Dr. Green’s office on May 8th asking if she could get an appointment to see him due to pain under her ribcage. The secretary that took this message was Nicole Lewis, an intern student that has worked for Dr. Green’s office for six-months. According to Nicole, she incorrectly wrote down Ms. Edward’s phone number and could not remember her first name, therefore, Dr. Green never received the message. Unfortunately, the COVID pandemic, caused many appointments and follow-ups to be delayed. On the 18
th
of May, Ms. Edwards was rushed to the ER at Christus Frances Hospital at 5:42 pm. The attending ER physician that saw Ms. Edwards was Dr. Kenneth Stein, a 10-year ER physician. Dr. Stein order the x-ray of Ms. Edwards and upon the initial scope
3 of her x-ray, it was discovered that there was a foreign object left inside the patient. On the 20
th
of May, Ms. Edwards underwent surgery to remove the foreign object. The physicians were Dr. Lisa McComb and Dr. Lawrence Hall, as requested by Ms. Edwards and her family. According to hospital records, Ms. Edwards was admitted on the 6
th
of April to have a pericardiectomy, which is the removal of all or part of the pericardium. The surgery took several hours with minimal complications. Ms. Edwards was placed in the recovery area for several hours and was closely monitored by Rita Howard RN, BSN, Rachel Scott RN, and Heather Lee LPN. Ms. Edwards’ vitals were taken very two hours as instructed by hospital policy and LaKeitha Robinson CNA, provided personal care to Ms. Edwards. Ms. Edwards remained a patient for five days and was released with orders to report any problems, a prescription for Percocet for the first 7 days then Tylenol afterwards. Ms. Edwards was also informed to make an appointment with a cardiologist for an echocardiogram six weeks after surgery. Ms. Edwards stated that 2 weeks after her surgery she began to have more pain under her ribcage area. She thought at first it was a part of the healing process; however, the pain continued and became too much to bear. Ms. Edwards stated that she called to make an appointment with Dr. Green on May 6
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unfortunately she was unable to reach anyone, and no one returned her message. It was not until May 8
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that Ms. Edwards was able to get through and make an appointment to see Dr. Green. The receptionist that took Ms. Edwards call was Nicole Lewis, who has been an employee at Dr. Green’s clinic for the past months. During the investigation, Ms. Lewis stated that she does remember Ms. Edwards calling to make the appointment, however, Nicole miswrote Ms. Edwards phone number and could not remember her first name and did not give the message to Dr. Green. Ms. Lewis also states that it was a busy day and the employee that was to be there to finish training Ms. Lewis had called in.
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4 On May 18
th
Ms. Edwards was rushed to the ER at approximately 5:42 pm complaining of chest pains due to complications of a recent surgery. The attending physician on duty was Dr. Kenneth Stein, a 10-year employee at Christus Hospital. Dr. Stein immediately order for Ms. Edwards to have a chest x-ray and an EKG done since she had recently had open heart surgery and was complaining of having chest pains. Dr. Stein withheld any pain medications until the results of the chest x-rays came back but he did order Ms. Edwards some Nitroglycerin 0.4 mg. After reviewing Ms. Edwards x-ray’s, Dr. Stein noticed an URFO, at which point Dr. Stein notified the house supervisor Neal Strong RN, BSN. A second x-ray was ordered and performed to verify if in fact the was an URFO in Ms. Edwards. After the second x-ray was viewed it confirmed that Ms. Edwards did have an URFO. Dr, Green along with Neal Strong contacted the HR department and a patient advocate counselor Patty Hurst. Dr. Green along with Patty Hurst, meet with Ms. Edwards and her family to inform them of their findings. On the 6
th
of May in 2020, Ms. Edwards had open heart surgery performed by Dr. Green and Dr. Karr at Christus Hospital at approximately 9:25am. A sales rep name Harry Boseman was present during Ms. Edwards surgery to assist the scrub tech “Sales rep must have had all immunizations that are required of all staff and surgeons” (Sentinel Event Alert issued on retained surgical items, 2013). The sales rep was assisting the scrub tech Josh Avery, with some new surgery equipment that the hospital is considering purchasing. Upon investigation, Harry Boseman stated that after the surgery was completed, he was missing a small surgical scalpel but was not sure where he left it. So, he did not inform the surgery staff that it was missing and not accounted for. According to the Joint Commission, a Sentinel Event Alert
was issued “urging surgery programs to take a new look at how to avoid mistakenly leaving items such as sponges, towels,
5 and instruments in a patient’s body after surgery” (Sentinel Event Alert issued on retained surgical items, 2013). The scrub tech Josh Avery, he handed Dr, Green several surgical instruments and he did not check to make sure that the surgical instruments were accounted for after the surgery. The negligence of the scrub tech and the sales rep led to the URFO to be left inside of Ms. Edward. Dr. Green and Dr. Karr were asked to give statements along with Josh Avery and Mr. Boseman giving detailed description of their actions before, during, and after Ms. Edwards surgery. A full investigation was done by the Department of Public Health of Louisiana and the Clinical staff at Christus Hospital. Upon their investigation their findings state that there was gross negligence on behave of Christus Frances Hospital and its’ surgical team which lead to the unnecessary injury of Ms. Edwards. The hospital has since incorporated extra training for its’ surgery staff and other departments of the hospital to avoid future sentinel events from occurring. As of 2019, the Joint Commission identified URFO’s as the most common sentinel event among the different adverse events that take place within the hospital setting (Tabibzadeh, 2020). The NCR which stands for the U.S. Nuclear Regulatory Commission, proposed a risk assessment framework that consist of six layers. These layers consist of the government, regulators, and associations, company, management, and staff. This analysis assesses the activities of each team player and their interactions within each layer (Tabibzadeh, 2020). In 2012, the INPO the Institute of Nuclear Power Operations established the AcciMap, to proactively analyze risks of failures, issues, and accidents (Tabibzadeh, 2020). HIPPA (Health Insurance Portability & Accountability Act, requires that all personal to adhere to hospital compliance as part of its approval process ((Sentinel Event Alert issued on retained surgical items, 2013). All these
6 agencies strive to reduce URFO’s from happing by training medical staff and bringing awareness concerning these issues and compiling ideas to eliminate such issues. Part 2: Root Cause Analysis (Fishbone Diagram) (Fishbone Diagram.pdf
Part 3: Root Cause Analysis Report The data I collected consisted of statements from Dr. Green, Dr. Karr. As well as the sales rep Harry Boseman and Josh Avery the scrub tech. Each person will be asked to give a clear and precise statement as to the event that took place on May 6
th
, 2020 the day of Ms. Edwards surgery. After reading and reviewing other documents and statements given by other medical staff, I was able to analyze how the URFO was misplaced and was not reported missing. Mr. Boseman did have permission from Ms. Edward and the hospital to be present during the operation. Mr. Boseman did meet all requirements to be present during surgery, however, Mr. Boseman neglected to report the missing surgical instrument to the medical staff team. My investigation also finds that
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7 Josh Avery, the scrub tech was negligent as well. He failed to perform a check-off of all surgical equipment before and after surgery. Had the those involved taken the necessary precautions this sentinel event could have been avoid. Further investigation revealed that the lack of training of new staff or the use of refresher courses were no longer being assigned to the medical staff as indicated in hospital policy. Reports also showed that staff members were not in compliance with HIPPA regulations or the AcciMap. Incorporating these methods will provide Christus Hospital with the means of preventing URFO’s from occurring and can educate its staff about the consequences of a weak safety culture in its’ OR procedures by implementing effective actions that will improve safety (Tabibzadeh, 2020). Probable Cause The Probable cause of this sentinel event was the negligent behavior of Mr. Harry Boseman, the sales rep and Josh Avery the scrub tech. Mr. Boseman, neglected to report the missing surgical equipment. Mr. Boseman has been reported to his supervisor and placed on administrated leave until the completion of this investigation. Josh Avery has been suspended pending the results of this investigation due to his failure to properly account for all surgical equipment used during Ms. Edwards surgery. The emergency department was found to be noncompliant with hospital regulations and policies. There was a lack of consistent training for new employees nor were there any retraining for existing employees informing them of new policies and procedures. Human Factors
The negligence from human factors consists of not reporting missing equipment to staff to prevent the URFO from occurring. Each staff member of the surgery/operating department should
8 well trained at keeping account of all used and unused medical/ surgery equipment. There should be a daily log that documents each shift usage and tracks all surgical equipment used. However, when managers neglect to enforce training then events such as URFO’s occur. Process Errors
According to Stephen Trosty, “Have a list of all instruments and other items that will be used in a case, and check these before the procedure begins” (Sentinel Event Alert issued on retained surgical items,2013). In this case, neither Josh Avery nor Harry Boseman followed this important step. Incorporating this step of checking all equipment used during a procedure will in fact eliminate the possibility of URFO’s. Missed Steps
Mr. Boseman should have reported that he was missing an instrument and not assumed he left it at another facility. He did not follow up on any type of search nor did he notify staff so that an inquire could have been in forced into this matter. Equipment Performance Although, Mr. Boseman had permission to be present during the procedure, he failed to keep an accurate account of all equipment present in the operation room. There was not an employee designated to keep account of equipment used. Hospital is now implementing having a training surgical tech present during all surgeries to keep an accurate record of all equipment used during surgeries. Due to this negligent behavior a patient was harmed, and the hospital faces possible charges. Staff Performance On May 8
th
, when Ms. Edwards spoke to Nicole Lewis, the secretary at Dr. Green’s office. Ms. Lewis failed to properly collect all of Ms. Edwards’ information and due to her lack of training
9 Ms. Lewis failed to inform Dr. Green about Ms. Edwards request to ben seen. This resulted in a further delay of discovering the URFO in Ms. Edwards. Ms. Lewis has been terminated due to her lack of professionalism. Josh Avery and Harry Boseman did not show professionalism either, both of them displayed the lack of ability to perform their jobs with the required skill or experience. Corrective Action Plan Here, develop a corrective action plan that is geared towards eliminating future events. Explain the steps of implementing the corrective action plan. Writing at least a paragraph for each section, discuss the elements below in your response. Risk Reduction Strategies Being by identifying the best risk reduction strategies. Improvement of Processes or Systems How can the processes or systems be improved to eliminate future events? Communication Barriers
Discuss the communication breakdown that may have contributed to the sentinel event. What barriers may have occurred to cause the breakdown in communication? Some of these may include residual intimidation, reluctance to report to a coworker, missing information at time of transition of care, etc. Training What training should be implemented to eliminate future events? This may include orientation, professional development, cultural competency, skills training, in-service, etc. Equipment
What equipment should be considered to eliminate future events? This should include the technology, maintenance, and updates.
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10 Policies and Procedures
What new or revised procedures should be considered to eliminate future events? Monitoring Process Describe the monitoring process that will be used to evaluate the success of the corrective action plan. Reallocation of Budgetary Resources
Analyze the components that may require the reallocation of budgetary resources. In this paragraph or series of paragraphs, you will want to consider legal action, public relations (reputation leading to decreased revenue), equipment and supplies, training and education, patient-
centered communication methods (informed consent, procedural education, patient involvement [identify or mark the location of the surgical site]), and staffing (reallocating staff, role responsibilities, hiring temporary or permanent staff). Conclusion Restate the conclusion or overall recommendation of the report. Recap the main points. Hint
: Ctrl + Click INTRODUCTIONS & CONCLUSIONS
for help developing a conclusion.
11 References Use APA Style 7
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Edition to cite and reference at least eight credible sources (four of which must come from the Ashford University Library). Remember, you MUST include in-text citations throughout your paper to show your reader what information you used from these sources. Sentinel Event Alert issued on retained surgical items. (2013). Same-Day Surgery, 37(12), 135–
136. Siobhán Corrigan, Alison Kay, Katie O’Byrne, Dubhfeasa Slattery, Sharon Sheehan, Nick McDonald, David Smyth, Ken Mealy, & Sam Cromie. (2018). A Socio-Technical Exploration for Reducing & Mitigating the Risk of Retained Foreign Objects. International Journal of Environmental Research and Public Health, 15(4), 714. https://doi-org.proxy-
library.ashford.edu/10.3390/ijerph15040714 Tabibzadeh, Maryam. Proceedings of the International Symposium of Human Factors and Ergonomics in Healthcare Volume: 9 Issue 1 (2020) ISSN: 2327-8595 Online ISSN: 2327-8595 Hint
: Ctrl + Click FORMATTING YOUR REFERENCES LIST for help formatting each of your sources.