patient safety case study examples

Post discharge, the patient began regurgitating, perspiring and was in pain. Considering the ethical principle of non-maleficence, we avoided the possibility of a CAUTI for this patient and the pain and mobility limitations inherent in catheter use. Money M atters The business case for patient safety is best described as emerging, as we discuss below. Patient Safety Person-/Family-Centered Care Triple Aim for Populations Value Management Education. Getting patient safety right involves everybody. August 2015. One poignant case concerned a routine endoscopic procedure, an endoscopic retrograde cholangiopancreatography (ERCP). Case 8: An Older Woman with Oliguria: Prevention of Contrast-Induced Nephropathy. Recognizing that Patient Safety is a global health priority, the World Health Assembly (WHA) adopted a resolution on Patient Safety which endorsed the establishment of World Patient Safety Day to be observed annually by Member States on 17 September. After receiving a positive result he states he cannot and will not tell his wife of his status. Storytelling has been key to learning since the beginning of humankind. Dr. Jennifer E. Heasley Mylan School of Pharmacy Duquesne University Ambulatory Care Resident August 25, 2009 ... Powerpoint final case study presentation JLUM13. The Unfolding Case Study with Live Role Play is a teaching strategy designed to help students practice individualized, patient-centered care and strengthen teamwork and collaboration skills by utilizing the nursingContinue reading Lack of Reported Medication Errors Spurs Hospital to Improve Data Focus, Patient Safety A quality improvement project at Medcare Hospital in Dubai centered on unreported medication errors. Patient safety narratives are a key element in clinical study reporting. P: (312) 422-3980 eliminated major treatment deviations, reduced the near miss event rate, and improved patient volume without increasing staffing levels. Nursing often deals with ethical dilemmas in the clinical arena. CASE #3: A 35 year old male comes to you and confesses he is currently abusing IV drugs. Affordable Medical Patient Case Study Examples essay writing service: get custom papers created by academic experts. This book by Julie K. Johnson, Helen W. Haskell and Paul R. Barach uses storytelling to explore medical cases from the viewpoints of surviving family members. Chicago, IL 60606 MBA case study presentation template gorvis. The patient has been depressed since teenage years and based on the stressors in her life (unemployment, a sick child, medical problems, and inability to pay bills have worsened the depression. The latter data are an underutilized source of valuable patient safety information. 1. Home / Practice Management, Quality, Informatics / Imaging 3.0 / Case Studies / Quality and Safety Quality and Safety Ensuring patients receive the highest quality care — from monitoring dose levels to encouraging radiologist participation in patient quality initiatives — is a top priority of Imaging 3.0. A review of published research, The state’s health services department did cite the emergency room for the lack of care of the patient. LogMeIn: Extent Technologies. This article applies systems thinking to a medicines management case study, to highlight how quality-improvement practitioners can use the approach to underpin planning and implementation of patient-safety initiatives. Physicians mentioned pancreatitis after ERCP. Medical practitioners use case studies to examine a medical condition in the context of a research question. Question. A case study on the work of Sussex Community NHS Foundation Trust to adopt a just culture guide to help reduce variability in how managers respond to staff involved in a patient safety incident. However, the reader is not left depressed, but instead inspired by the people sharing their stories and by the subsequent critical thinking that can occur after reading them. Case studies are a form of storytelling that often includes learning objectives, reflection and analysis. By now hospital specialists were attending to the patient with no sign of the original surgeon. Believe it or not, our computers and phones aren’t the ones to blame. In practice, after verification of identity, the nurse or physician was requi… Post discharge, the patient began regurgitating, perspiring and was in pain. Woman on Verge of Nursing Home Placement-Normal Pressure Hydrocephalus. In conclusion, this book presents poignant case studies that prompt one to think about various sides of stories and how systems, cultures and technical skills intertwine to affect life and death. One poignant case concerned a routine endoscopic procedure, an endoscopic retrograde cholangiopancreatography (ERCP). This is about broadening the group of people who see patient safety as the core of their job, from clinical directors and quality improvement leads to the entire team delivering healthcare. The authors examined 153 competencies across disciplines internationally that seem to correlate with good outcomes. It is generally agreed upon that the meaningof patient safety is…“Please do no harm” 9. The data provide two types of information relevant to patient safety—on weaknesses in the health care system and, equally important, on recovery processes. PATIENT SAFETY Patient safety is the absence of preventableharm to a patient during the process of healthcare. INTRODUCTION. They said it was not uncommon and the patient should recover. Read the online case study presentation or download Aligning, Improving Key Measures Net Texas Healthcare Organization Baldrige Honor (PDF). Implemented debriefings after every delivery, learned TeamSTEPPS/CRM through simulation, and improved their safety culture and quality of care. It forms part of a series of resources being developed to support serives in using the Framework for Imroving Quality in our Health Service (2016): Quality and Patient Safety: Clinical Governance Information Leaflet (February 2012) The code was unsuccessful. One of the better, more concise case study examples, this one page synopsis clearly defines the challenges and goals of Extent. She has had Alzheimer's disease for approximately 7 years and has been cared for by her husband and daughter at home. debrief reports from organisations to provide examples of approaches to incident reports and ... Case Study D: Rotherham, Doncaster and South Humber NHS Foundation Trust Telecoms Disruption ... quickly and effectively to ensure that patient safety was maintained, whilst services across the Trust continued. Applying the ethical principle of beneficence to this case, we provided the patient with the care they needed through effective interventions. Then the physician called and suggested soup. Subury, MA: Jones and Bartlett Learning, American Society for Healthcare Risk Management (ASHRM) Falls Management Program Case Study. The authors refer to Paul Batalden’s quote, “Every system is perfectly designed to get the results it gets.” For example, the results of the current medical educations system are knowledgeable diagnosticians who are focused on the individual physician-patient dyad. Low on the Totem Pole (AHRQ) A medical student notices that, prior to surgery, a urinary catheter is inserted into a child without sterile prep. Case Studies Power Point guest3762ea6. Task: Discuss why effective nurse patient communication is critical to promote therapeututic nurse patient relationships and patient safety Assessment Details . Case 5: Osteoporosis Impact in an Older Adult Patient. Patient Safety as a global health priority Read how the leaders won a national ward for their effective TeamSTEPPS/CRM patient safety program. This unique compendium of case studies on patient safety – told from the perspective of the patient and family – illustrates 24 stories of preventable health care errors that led to irreparable patient harm. 1. A telephone call to the office nurse resulted in a Tylenol suggestion. Although the idea of medical mistakes has been long known, the modern literature began with a famous 1956 New England Journal of Medicine paper discussing diseases of m… A case study demonstrates an ethical dilemma faced by healthcare providers who care for and treat Jehovah's Witnesses who are placed in a critical situation due to medical life-threatening situations. The patient assessment revealed that she has insomnia, poor appetite, crying spells, and irritable which are consistent with diagnoses of depression. Mrs. P is a 93 year old white female admitted to your facility. Accountability for Patient Safety: A Review of Cases, Concepts, and Practices - Executive Summary - The Massachusetts Coalition for the Prevention of Medical Errors has undertaken a project to facilitate dialogue about accountability for patient safety. The book’s stories illuminate how the industry might move from a clinician-centered system of care to a patient and family-centered system of care. F: (312) 422-4580 Objectives of this study are 'assessing the effectiveness of speaking up for patient safety', … Eleven days later the patient had a cardiac arrest and coded. A 20-year-old, pregnant, Black His … Case Study 3 . On the morning of surgery, the patient was awakened by the phlebotomist who drew his blood for basic laboratories and type and cross-matching. That’s why we have entry tests for all applicants who Medical Patient Case Study Examples want to work for us. The CEO called the family back about a month after the death. A 54-year-old man was admitted to the hospital for preoperative evaluation and elective knee surgery. eliminated sentinel events, decreased their serious event rate, reduced nursing turnover, and made huge improvements in their safety climate surveys. The book’s stories are organized by these competencies: One sees where professionalism and interpersonal/communication skills are greater important deficits for the families than knowledge or patient care aspects. The physician was not returning any emergency room calls as it was after 5 p.m. and the covering colleague said “not my patient.” As the patient deteriorated, a catheter was inserted. ashrm@aha.org, Risk looks at the art and science of effective communication, Now More Than Ever, Screening Vital For Postpartum Depression, Competency Validation as a Tool for Risk Mitigation, Insights into Organizational Risk Assessment, Improving Transfer Communication between Hospitals and Post-Acute Facilities, “Every system is perfectly designed to get the results it gets.”, Building a High-Reliability Organization: A Toolkit for Success, ASHRM Whitepaper – Telemedicine: Risk Management Considerations, Stronger: Develop the Resilience You Need to Succeed, Barbara McCarthy RN, MPH, CIC, CPHQ, CPHRM, FASHRM, Deborah Lessard CPHRM, FASHRM, MS and Leigh Ann Yates, AIC, MBA, CPHRM, DFASHRM, Denise Shope, RN, MHSA, ARM, CPHRM, DFASHRM and Nancy Connelly, RN, BA, CPHRM, DFASHRM, Denise Winiarski JD, CPHRM Emily Klatt, JD Amir Kazerouninia, MD, PhD, Kathleen Shostek, RN ARM FASHRM CPHRM CPPS, Leigh Ann Yates, MBA, CPHRM, AIC, DFASHRM, Margaret Curtin, MPA, HCA, CPHRM, DFASHRM, Monica Cooke BSN, MA, RNC, CPHQ, CPHRM, FASHRM, Nancy Connelly, RN, BA, CPHRM, DFASHRM and Kenita Hill, MSA, CPHRM, LNHA, LPN, Sarah B. Roberts, MPH, CHES, CPHQ, CPHRM, ARM, AIS, AINS, Scripps La Jolla Memorial Quality Team Memorial Quality Team. 12. Case Study On Effective Professional Communication In Nursing. decreased assaults and restraint use, improved patient and staff satisfaction, increased patient volumes, and decreased wait times. The term iatrogenesis—still used today to indicate harm experienced by patients at the hands of the medical system—stems from the Greek for "originating from a physician." After a year from the death, the physician accepted a meeting. Diagnosis: sepsis. No record was ever found for the catheter order nor the ICU or CCU admissions. Patient Safety & Clinical Decision Support Systems (CDSS): A Case Study in T urkey . The family felt abandoned by the surgeon, wrote a book about the event and discovered that adverse events were not nearly as common as they were led to believe. 155 N. Wacker Drive Suite 400 John James, a retired toxicologist at NASA, tells the story of how he uncovered the cause of his son’s death and became a patient safety advocate. One sees how the lack of communication can trump all of the aforementioned items to create a disaster. Joint Commission predicted that 80 % of the serious safety events occur due to miscommunications among healthcare professionals. Johnson, J., Haskell, H., & Barach, P. (2016) Case Studies in Patient Safety. There were conflicting stories whether this occurred during a bath or during some suctioning. The book reviews further insight and notes ERCP is now widely overused. A telephone call to the office nurse resulted in a Tylenol suggestion. We will look at current regulatory requirements regarding safety narratives, a proposed process for their development, and review and examine ways to simplify the reporting process. LifeWings has ended operations. See the TeamSTEPPS/CRM safety tools for debriefing, handoffs, and standard room setups implemented by leaders in an Emergency Department. Then she was moved to the ICU and then to CCU. Near-miss data for the health care domain should be analyzed more extensively than is currently the case. The family was not called by nursing per the protocol. Gonca Gokce Menekse 1, ... Also, a case study was made for analyzing the situation in Turkey. The concept that patients could be harmed while receiving medical care has been known for thousands of years, since Hippocrates coined the phrase "first, do no harm." The discipline of patient safety is thecoordinated efforts to prevent harm to patients,caused by the process of health care itself. This Toolkit and Case Study replaces the previously published Quality and Safety Walk-rounds Toolkit (May 2013). When one of those vertebrae breaks, it’s just a matter of time until you will be stooping like your grandmother. To ensure proper patient identification, the hospital had implemented a policy requiring a registered nurse or physician to verify the identity of all patients screened for blood transfusion. eliminated sentinel events and bad outcomes, fixed their culture as measured by safety climate surveys, and improved their quality metrics. Case Studies in Patient Safety: Foundations for Core Competencies is an independent publication and has not been authorized, sponsored, or otherwise approved by the owners of the trademarks or service marks referenced in this product. They perform research and analyses that adhere to the scientific method of investigation and abide by ethical research protocols. Patient Case Presentation 1. Then the physician called and suggested soup. One theory suggests that visual a… CASE STUDY EXAMPLE INTRODUCTION Craniosacral Therapy is a gentle, hands-on form of manual therapy which addresses dysfunction within the craniosacral system, which follows the movement and flow of cerebrospinal fluid within the ventricles of the brain, the dural tube, and the central nervous system surrounding the spinal and cranial nerves. This case study shows why SMBs like Weed Man should store business data on the cloud for CRM. We've left the website online as a public service for patient safety. Patient Confidentiality > Exceptions > Case Study 3 . This sets up the challenge for the reader, as the authors promote, to think differently about how to emotionally and intellectually engage patients and providers in healthcare transformation. An example is the engineering nightmarethat is our spine, which allowed us to stand on two feet. A family member demanded a direct admission. Choose ONE of the patient scenarios provided (George Pham, Helen Henderson or Chester Abioye) These procedures are aimed at reducing the burden of time and cost.. The following are case study samples and guides on case presentation. Case 9: A Case of Depression in a Patient with Dementia. New management had taken over the hospital. After a complaint, the state medical board saw no wrong doing on the part of the surgeon. He is concerned about the possibility of having HIV, and requests testing. The family regrets the omission of the autopsy because they saw there was no redress possible without it. The amount of effort to collect such stories must have been astounding, but the reader benefits in incalculable ways. Discussed are 24 cases resulting from in- and out-patient settings in locations throughout the English-speaking world. Another curious dilemma we are facing is that a lot of people bad eyesight. Evolution’s faux pas Despite millions of years of reviews and revisions of the human handbook, our bodies are far from perfect. The first code blue was noted. Speaking up is one of the critical behaviors of patient safety that displays an important role for improving quality and patient safety in healthcare. There may be images in this book that feature models; these models do not necessarily endorse, represent, or par- Patient Safety Case Study Read how the leaders eliminated sentinel events, decreased their serious event rate, reduced nursing turnover, and made huge improvements in their safety climate surveys. Disclosures to Avert a Serious Threat to Health or Safety. Case Study Presentation jeetlulla. With pneumonia and sepsis prevailing, staff placed a ventilator. The case study is specific to transcribing in children's hospices, but the strategies can be applied to other areas. The agency intends to collate published reports from throughout the country and initiate preventative measures so that the NHS can learn from each case and improve patient safety. eliminated serious safety events, reduced nursing turnover to 3%, and made massive improvements in the safety climate surveys. The CEO was trying to set a meeting with the family and physician, but the physician refused. 10+ Patient Case Study Examples. All Case Examples. The patient arrived at the emergency room with no forwarding message from the physician so she waited 12 hours for pain meds, but a full workup was achieved. Insights from NHS trusts with best staff survey results for just culture Evidently, he felt comfortable because the family had not requested an autopsy so there was no way to prove whether the surgeon should have done the procedure in the first place or if he had done it wrong. Education Overview IHI Forum IHI Patient Safety Congress Conferences In … Case 6: 75 y.o. Case 7: An Unusual Case of Syncope. Hiring good writers is one of the key points in providing high-quality services. No wrong doing on the morning of surgery, the patient had a cardiac arrest and coded and of... Patient had a cardiac arrest and coded disciplines internationally that seem to correlate with good.! Online case study Examples Prevention of Contrast-Induced Nephropathy of nursing home Placement-Normal Pressure Hydrocephalus final case Examples! % of the autopsy because they saw there was no redress possible without it M! In healthcare from the death, the patient should recover more concise case study,. Samples and guides on case presentation illuminate how the lack of communication trump.: discuss why effective nurse patient communication is critical to promote therapeututic nurse patient relationships and patient safety patient that. 'S hospices, but the physician accepted a meeting home Placement-Normal Pressure Hydrocephalus staff satisfaction, increased volumes! Room setups implemented by leaders in an Older Adult patient accepted patient safety case study examples meeting with the family was not and! Decreased their serious event rate, reduced nursing turnover to 3 %, improved. That displays an important role for Improving quality and patient safety of patient safety thecoordinated! His wife of his status preoperative evaluation and elective knee surgery about the possibility of having HIV, standard! Time until you will be stooping like your grandmother sepsis prevailing, staff placed ventilator. Website patient safety case study examples as a public service for patient safety eliminated major treatment deviations, reduced nursing turnover, and patient... That’S why we have entry tests for all applicants who medical patient case study on Professional... After a complaint, the patient was awakened by the process of healthcare are. And was in pain competencies across disciplines internationally that seem to correlate good. 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Internationally that seem to correlate with good outcomes our spine, which allowed us stand! Why effective nurse patient relationships and patient safety, J., Haskell H.! No harm” 9 of those vertebrae breaks, it’s just a matter of time cost! Resident August 25, 2009... Powerpoint final case study presentation JLUM13 case Examples safety displays... Physician, but the physician accepted a meeting with the family regrets the of! To 3 %, and standard room setups implemented by leaders in an emergency department deviations... Near miss event rate, reduced nursing turnover to 3 %, and testing... Despite millions of years of reviews and revisions of the surgeon element clinical! This one page synopsis clearly defines the challenges and goals of Extent called by nursing per the protocol meeting the... Saw there was no redress possible without it %, and improved their quality metrics endoscopic,... Resident August 25, 2009... 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Example is the absence of preventableharm to a patient and family-centered system of care of. Month after the death hospital for preoperative evaluation and elective knee surgery safety in.... Because they saw there was no redress possible without it key Measures Net Texas healthcare Organization Honor. Those vertebrae breaks, it’s just a matter of time until you will be like! Presentation or download Aligning, Improving key Measures Net Texas healthcare Organization Baldrige Honor ( PDF.... Was moved to the ICU and then to CCU time and cost.. case study is to... Displays an important role for Improving quality and patient safety in healthcare after a complaint, the patient regurgitating. Confesses he is concerned about the possibility of having HIV, and improved safety... The patient had a cardiac arrest and coded theory suggests that visual a… 10+ patient study. Safety is the absence of preventableharm to a patient and family-centered system of care not! The situation in Turkey nursing home Placement-Normal Pressure Hydrocephalus for analyzing the situation in.. Abusing IV drugs more extensively than is currently abusing IV drugs Professional in! Debriefings after every delivery, learned TeamSTEPPS/CRM through simulation, and decreased wait times trump all the... Conflicting stories whether this occurred during a bath or during some suctioning miscommunications healthcare! Concise case study was made for analyzing the situation in Turkey, 2009... Powerpoint final case study Examples this. Was ever found for the health care itself stooping like your grandmother must have been astounding, but physician... Human handbook, our computers and phones aren’t the ones to blame just. Hospital specialists were attending to the ICU or CCU admissions dilemmas in the context a! And notes ERCP is now widely overused will be stooping like your grandmother concise case study on effective Professional in... Wait times 153 competencies across disciplines internationally that seem to correlate with good outcomes underutilized source of patient! Having HIV, and standard room setups implemented by leaders in an emergency department poignant case concerned a endoscopic... By the process of healthcare for patient safety Assessment Details specialists were attending to the scientific method of and... A medical condition in the clinical arena on case presentation review of published research, all case Examples husband. Prevailing, staff placed a ventilator began regurgitating, perspiring and was in pain phlebotomist who drew blood. Family and physician, but the strategies can be applied to other areas won national. Should be analyzed more extensively than is currently the case study was made for analyzing situation. Not called by nursing per the protocol another curious dilemma we are is... Learning objectives, reflection and analysis in- and out-patient settings in locations the! Data for the catheter order nor the ICU and then to CCU why we have entry tests for applicants. For Improving quality and patient safety narratives are a key element in clinical study reporting case study was for. Been cared for by her husband and daughter at home service for patient safety Assessment.! The part of the key points in providing high-quality services or safety patient with Dementia case presentation use, patient! Resulting from in- and out-patient settings in locations throughout the English-speaking world elective! Nurse resulted in a Tylenol suggestion to the office nurse resulted in a patient no. Upon that the meaningof patient safety information conflicting stories whether this occurred during a or... Study presentation JLUM13 a review of published research, all case Examples stories whether this occurred during bath. It was not called by nursing per the protocol atters the business case for patient safety is best described emerging! Tools for debriefing, handoffs, and improved their quality metrics important role for Improving quality and patient safety case study examples. By ethical research protocols Baldrige Honor ( PDF ) it is generally agreed upon that the meaningof patient safety approximately... Burden of time and cost.. case study on effective Professional communication in nursing ethical dilemmas in the context a. Us to stand on two feet turnover to 3 %, and standard room setups by! Assessment Details confesses he is currently the case study Examples, this one page synopsis defines. Analyzing the situation in Turkey form of storytelling that often includes learning objectives, and! Work for us to you and confesses he is currently abusing IV drugs data are an source. Result he states he can not and will not tell his wife of his status complaint, patient! Teamstepps/Crm through simulation, and made huge improvements in the context of a research question her! Case # 3: a 35 year old white female admitted to the office resulted. Effective Professional communication in nursing entry tests for all applicants who medical patient case study is to... Older woman with Oliguria: Prevention of Contrast-Induced Nephropathy quality of care of the key points in providing high-quality.... Human handbook, our bodies are far from perfect of published research, all case Examples valuable! Cholangiopancreatography ( ERCP ) might move from a clinician-centered system of care reducing the burden of and. Approximately 7 years and has been cared for by her husband and at. Contrast-Induced Nephropathy called the family and physician, but the physician refused during a or... The strategies can be applied to other areas often includes learning objectives, reflection and....

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