In the book \"Patient Safety for Health Professionals,\" it states: \"In April o

Question

In the book "Patient Safety for Health Professionals," it states: "In April of 1990, I experienced an unexplained pain in my groin. The pain was so acute that I went directly from work to the emergency room (ER). The ER physican suggested that the problem was most likely a hernia, but he was not certain. He let me knw that a refferal to a urologist by the ER would be necessary to confirm the diagnosis. He said that I should expect a call from the urology service within a week or two. The ER intiated no additional follow-up about my progeress after my visit. In July (3 months after my ER visit), with summer vacaton plans looming, I realized the urology department had not yet contacted me. During this 3-month period, the pain came and went. I quickly learned to avoid certain activities (like earning more tha a "B" in my tennis class!). In mid July, I took it upon myself to call urology. By late July, I finally saw and was evaluated by a urologist, and the hernia diagnosis was quickly confirmed. The urologist indicated that the course of treatment was surgery. I went to see a surgeon. After a couple of outpatient visits for evalutation, the surgeon perfrmed an outpatient surgical precedure to repair my hernia. In a follow-up with the surgeon 2 or 3 weeks later, he told me that unless I expeirenced any additional pain or complication I was finished with this episode of care. During this visit, the surgeon could not find any record of the surgery in my chart, although he was sure he had personally operated on me and I was sure because I was still feeling the pain of recovery. One month after my sucuessful surgery I recieved a call from the urology department to schedule me for an appointment,. Under the impressoin that my episode of care was complete, I asked why they were calling me to schedule an appointment. They quickly responded that they had recieved a referral from the emergency department (better late than never, I guess!).

You are the organizational consultant brought in to help resolve the situation surrounding this case. Although there was no real harm to the patient, the health system CEO is concerned that a similar scenario surrounding a malignant melanoma or other equally serious diagnosis might result in significant patient safety issues and liability for harm.

1. What error(s) occurred in this case? Describe how individual and organizational approaches to error might explain the errors that occurred. How did the organization contribute to the occurrence of error(s)?
2. How might a high-reliability organization respond to the discovery of such error?
3. List and describe likely organizational characteristics that created the environment in which the error(s) occurred.
4. How might technology have contributed to or reduced the possibility of the error(s)?
5. List strategies that the organization could implement to motivate healthcare workers to become part of a culture of safety and ultimately do the right thing.

Explanation / Answer

1. After patient visit ER team has not taken initiative to contact urologist and organise follow up for the patient. Even patient has supress his pain for consecuative three months and later took a charge byhimself to contact urologist. From both sides error has conducted. it was ER team responsibilty to organize a follow up for patient as soon as possible in order to the get the treatment within time.

2. High-reliability organization will take this matter seriously and will take action for the team who has taken responsiblity of booking an appointment for the patient. Committee has all the rights to question ER team about the case and to expect an explaination regarding the issue.

3. Misplaced of the documents of the patient, Lots of cases on the same day, Two patient of the same name etc. can be the cause of such error.

4. Technology might have reduced such error as all the data entry would have been done by electronic method where papers work is not required and appoinment would have been booked by electronic manner where patient would have recived notification about his appointed schedule soon after it was booked.

5. Healthcare workers should keep a track of each patient details by using electronic health record method or maintaing a hard copy file for each patient.

Revalidation of data of each patient should be done individually by health care members.

Communication with patient could be document so that no such error or confusion can occur in future.

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