1. System-Wide Safety Failures every system is perfectly designed to achieve the
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Question
1.System-Wide Safety Failures
every system is perfectly designed to achieve the results it gets.
—Dr. Paul Batalden
In the years following the publications of To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century, increased attention was given to mitigating the circumstances in which patient safety is compromised. Increasingly, adverse events that occur within healthcare organizations are recognized, not as the failure of any individual (health provider or patient) but as system-wide failures. High-profile sentinel events, such as Libby Zion, Josey King, and the Quaid twins, to name a few, have attracted public attention and spotlighted the tangled or missing systemic threads that can lead to serious outcomes. Likewise, in this environment, adverse events that might cause little or no harm are gaining increased attention. This shift in perspective is having a profound and ongoing impact on how healthcare is delivered, regulated, and reimbursed.
Bring to mind an adverse event that has been publicized or one with which you are familiar, one for which there was a resulting systems change. With this event in mind, respond the following:
Analyze the adverse safety event that became an impetus for systems changes related to patient safety as follows:
Describe the event and its effects on key persons involved. (2–3 paragraphs)
Explain the systemic failure that allowed the event to occur. (2–3 paragraphs)
Explain system changes that were made as a result of this event as well as the outcomes of those changes. (2–3 paragraphs)
Explanation / Answer
An event in a healthcare sector is called an adverse event when an unintended harm is caused towards the patient and his/her family by an act of omission or commission instead of an underlying condition or disease. Most of the adverse events go undetected because of the reliance on voluntary reporting by most health care organizations rely for the detection of adverse events. Some serious reportable incidents are surgery of the wrong body parts; surgery on wrong patients; retention of a foreign object in a patient after surgery, death of a patient due to the use of contaminated drugs; medication error resulting in patients death and short circuit, burn, etc causing death of patients.
The event in this case is from Thane civil Hospital, Mumbai, Maharashtra, India. The case involved a couple who lost their baby during delivery in the year 2008. It was due to negligence on the part of doctors. One of the doctors, Dr Nandpurkar advised delivery by a Caesarean section when the would be mother was admitted resulting from a labor pain. She was left unattended for four hours, as Nandpurkar allegedly went off to attend to patients at her private clinic which resulted in the baby getting stuck during labour and choked to death (Singh, 2016).
It was a huge mental trauma for both the parents to lose their child in mother's womb. Allowing a doctor from a government run hospital to have his own private clinic and that too no restriction on practice in the days when he is not free was a colossal failure of the system which helped in the occurance of such an adverse event. Another systemic failure was that there was no supervisor who could look after and managed that situation.
The state human rights commission adviced the Maharashtra government to initiate disciplinary action against three doctors for such a shameful event of which 1 fled the country, another systemic failure. The human rights commission order directed the state to pay the couple a Rs 5-lakh compensation with 12% interest per annum from the time of filing the complaint(Singh, 2016). Lately, there are very few reports coming from the hospital especially related to child delivery.
Reference
Singh, D. (2016). One of the worst cases of medical negligence in India. MumbaiMirror.
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