Reasons that lead to subsequent caregivers not recognizing that the patient transferred to, prepped for, and undergoing surgery was not the right patient
Root cause analysis (RCA) refers to an approach to problem solving which focuses on identifying the root causes of errors, problems and faults (Ross, 2014). A root cause is a causative factor, which once eliminated from the chronology of the event, prevents the final undesirable error from occurring. In this view, two main root sources created the error. These are overlays and duplicated medical records. In this case, an overlay occurred when two different patients, with names that almost sound similar, had their records intermingled and then the hospital staff chose the rose one for transfer, prep and surgery (Ross, 2014). A duplicate record occurs when hospital employees create multiple records for one patient. Often, duplicate records occur as a result of miscommunication and the pressure to record patients as fast as possible.
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Significance of data collection and data analysis in measuring the chronology of events
The ability to accurately and fairly collect and measure data is a prerequisite to assessing and improving the quality of healthcare delivered. It is impossible for healthcare practitioners to practically improve what they cannot measure. For them to measure the quality of care delivered, they need to collect and analyze good data. Data collection and analysis not only enables them to assess the quality of care also to measure the success of the improvement strategies (In Oster et al. 2016).
Steps that should have been taken to avoid this latent medical error
Nowadays, such latent medical errors have become way too common. Though it might be challenging to avoid them, it is possible if hospitals can embrace various approaches. The following are some general best practice steps that should have been taken to avoid this error.
The first step is to use different patient identifiers to confirm the patient’s identity at every encounter (In Oster et al. 2016). These identifiers may include the patient’s name, unique hospital number, date of birth, photo or social security number. As demonstrated in this case study, hospital employees should not rely on room numbers, diagnoses and bed numbers to identify patients.
The second step is to implement protocols for patients in the same department or unit sharing similar names. In this case, the patient misidentification occurred easily because the patients’ names almost sounded similar (Ross, 2014). Therefore, hospitals must have alternative identifiers for patients in this case. Also, it is important to avoid putting patients with similar names or with names that almost sound similar in the same room.
Finally, during hand-off, staff must note patient-specific identifies (In Oster et al. 2016). Most patient misidentification cases often occur during shift changes. This is attributable to poor handoff conversations. Therefore, staff should relay adequate information about the identifiers used for each patient and have patients confirm their identity upon the beginning of their shift.
Evaluate why and how humans produce errors and what precautions should have been taken in this case study.
Producing errors is the basic nature of nay living creature existing on Earth(Garber et al. 2010). Even when a machine wears, suffers from some defect or is improperly programmed, it will produce error. This implies that all creatures have some form of limitations. We are all prone to making mistakes. The following precautions should have been taken in this case study. First, the leadership in the hospital should have sponsored and modeled a “Just Culture”. In Avoiding common nursing errors, Garber and colleagues (2010) define a Just Culture as a model of shared accountability. In this culture, the hospital is held accountable for its systems and for how it responds to employees’ behaviors. In this culture, employees would not have been punished for their omissions, which were corresponding with their training and experience but where they demonstrate willful violations and gross medical negligence (Garber et al. 2010). Had the hospital nurtured this organizational culture, employees would have been willing to share error details. Sadly, in this case, the employees did not want to disclose details of the error because they feared that it might compromise with their professional status.
Another precautionary measure is to collect data post the incident (Garber et al. 2010). The hospital must collect data on the back-end to guarantee that improvements are introduced to the system and serve the purpose, which they were originally intended. Without these two precautions, the quest for hospitals to deliver safe care would be unlikely.
References
Garber, J. S., Gross, M., &Slonim, A. D. (2010). Avoiding common nursing errors .Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
In Oster, C., In Braaten, J., & Sigma Theta Tau International,. (2016). High reliability organizations: A healthcare handbook for patient safety & quality .
Ross, T. K. (2014). Health care quality management: Tools and applications .Somerset, NJ: John Wiley & Sons, Inc.ISBN: 978-1-118-50553-3
