Mrs. Jackson is a 58 year old female who entered the hospital via Pre-op admissi

Question

Mrs. Jackson is a 58 year old female who entered the hospital via Pre-op admissions on October 28, 2013. She was scheduled for a right knee replacement by Dr. Perez. The OR was busy and behind that morning due to an issue with humidity in the OR that required a maintenance crew to work with the system for one hour before the days scheduled cases could begin that morning. Several of the surgeons were becoming restless and verbal about the delays. Once the maintenance team completed the work on the air handling system, the OR humidity was retested and the OR rooms were re-opened. Dr. Perez insisted that Mrs. Jackson's procedure begin immediately. The nurses rushed the patient into the room. In the rush, the surgeon failed to mark the site of for the procedure. Nancy, the scrub nurse noticed but since Dr. Perez was in such a foul mood, she did not push the issue. Jack, the RNFA noticed that the knee X-rays were not on the x-ray view so ran out of the room, grabbed the x-rays from the desk just outside the room and flipped them onto the screen in the OR. In his rush, he did not use two patient identifiers to ensure the x-rays belong to Mrs. Jackson (they belonged to Mrs. Reick, who was scheduled for a Left TKR immediately after Mrs. Jackson's procedure. Once in the room, both anesthesia and Judy, the OR nurse called for a time out to check the consent, medical record and patient ID for the correct procedure, patient, site, etc. The members of the surgical team were still moving about preparing the 12 trays needed for the procedure. Judy was frustrated when she could not seem to get everyone to stop but she saw that Dr. Perez was "about to blow" so she continued with the time out. All participants in the time out confirmed that the patient was Mrs. Jackson, and that she would be having a Left Knee Replacement; no one checked the consent form. The procedure was begun and the procedure went very smoothly. It was not until the patient was in the PACU that Sam, the PACU nurse realized that the wrong site was completed. Directions As the VP of quality and risk management at the above hospital, you conducted the RCA on the above case. Discuss the following based on the event scenario above: What was the root cause(s) of the wrong site surgery? Which root causes are human factors and which were system factors? Based on the identified root causes, what opportunities do you see for improvement and what actions would you put into place to ensure that this adverse event would never happen again.

Explanation / Answer

What was the root cause(s) of the wrong site surgery?

There are such a significant number of encounters for the patient and negatively affect the surgical group. State licensure loads up are forcing punishments on specialists and a few guarantors have chosen to never again pay suppliers for WSS or wrong-individual surgery, nor for leaving an outside protest in a patient's body after surgery. Surgery performed on the wrong site or wrong individual has additionally regularly been held compensable under negligence claims.

The root cause of the wrong surgery here is Medical malpractice.

Which root causes are human factors and which were system factors?

"Therapeutic misbehavior happens when a social insurance expert or supplier fails to give fitting treatment, discards to make a suitable move, or gives substandard treatment that causes damage, damage, or passing to a patient,"

Normal underlying drivers are human components are recorded underneath:

Based on the identified root causes, what opportunities do you see for improvement and what actions would you put into place to ensure that this adverse event would never happen again.

Negligence claims against doctors and other human services suppliers are never again exclusively in view of mistake in therapeutic medications. They've turned out to be more about how a patient feels they were dealt with—or abused—by the guardian or medicinal services office. While this may appear to be nonsensical, it's world, and it's likewise why social insurance experts need to consider these 7 stages for keeping away from a misbehavior claim when performing

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