Exceptions > Case Study 3 . Patient safety narratives are a key element in clinical study reporting. 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. Speaking up is one of the critical behaviors of patient safety that displays an important role for improving quality and patient safety in healthcare. 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. Patient Safety & Clinical Decision Support Systems (CDSS): A Case Study in T urkey . 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. She has had Alzheimer's disease for approximately 7 years and has been cared for by her husband and daughter at home. 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. Case Study On Effective Professional Communication In Nursing. Case Studies Power Point guest3762ea6. Case 8: An Older Woman with Oliguria: Prevention of Contrast-Induced Nephropathy. A 20-year-old, pregnant, Black His … There may be images in this book that feature models; these models do not necessarily endorse, represent, or par- Discussed are 24 cases resulting from in- and out-patient settings in locations throughout the English-speaking world. After a year from the death, the physician accepted a meeting. The family regrets the omission of the autopsy because they saw there was no redress possible without it. The code was unsuccessful. Disclosures to Avert a Serious Threat to Health or Safety. 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. This case study shows why SMBs like Weed Man should store business data on the cloud for CRM. P: (312) 422-3980 LogMeIn: Extent Technologies. The amount of effort to collect such stories must have been astounding, but the reader benefits in incalculable ways. Johnson, J., Haskell, H., & Barach, P. (2016) Case Studies in Patient Safety. 10+ Patient Case Study Examples. 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. 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 Case Study Presentation jeetlulla. Dr. Jennifer E. Heasley Mylan School of Pharmacy Duquesne University Ambulatory Care Resident August 25, 2009 ... Powerpoint final case study presentation JLUM13. 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… Case studies are a form of storytelling that often includes learning objectives, reflection and analysis. 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. Case 9: A Case of Depression in a Patient with Dementia. The data provide two types of information relevant to patient safety—on weaknesses in the health care system and, equally important, on recovery processes. 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. Insights from NHS trusts with best staff survey results for just culture 155 N. Wacker Drive Suite 400 One sees how the lack of communication can trump all of the aforementioned items to create a disaster. Read how the leaders won a national ward for their effective TeamSTEPPS/CRM patient safety program. All Case Examples. 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. A telephone call to the office nurse resulted in a Tylenol suggestion. eliminated serious safety events, reduced nursing turnover to 3%, and made massive improvements in the safety climate surveys. Diagnosis: sepsis. Then she was moved to the ICU and then to CCU. 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 CEO called the family back about a month after the death. Case 5: Osteoporosis Impact in an Older Adult Patient. Another curious dilemma we are facing is that a lot of people bad eyesight. They said it was not uncommon and the patient should recover. Eleven days later the patient had a cardiac arrest and coded. Gonca Gokce Menekse 1, ... Also, a case study was made for analyzing the situation in Turkey. Nursing often deals with ethical dilemmas in the clinical arena. 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. Falls Management Program Case Study. Storytelling has been key to learning since the beginning of humankind. A family member demanded a direct admission. 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. Money M atters The business case for patient safety is best described as emerging, as we discuss below. 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… See the TeamSTEPPS/CRM safety tools for debriefing, handoffs, and standard room setups implemented by leaders in an Emergency Department. The patient assessment revealed that she has insomnia, poor appetite, crying spells, and irritable which are consistent with diagnoses of depression. One poignant case concerned a routine endoscopic procedure, an endoscopic retrograde cholangiopancreatography (ERCP). Read the online case study presentation or download Aligning, Improving Key Measures Net Texas Healthcare Organization Baldrige Honor (PDF). That’s why we have entry tests for all applicants who Medical Patient Case Study Examples want to work for us. Near-miss data for the health care domain should be analyzed more extensively than is currently the case. 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." 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. Case 6: 75 y.o. Applying the ethical principle of beneficence to this case, we provided the patient with the care they needed through effective interventions. 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. eliminated sentinel events and bad outcomes, fixed their culture as measured by safety climate surveys, and improved their quality metrics. He is concerned about the possibility of having HIV, and requests testing. An example is the engineering nightmarethat is our spine, which allowed us to stand on two feet. 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. Case 7: An Unusual Case of Syncope. F: (312) 422-4580 The CEO was trying to set a meeting with the family and physician, but the physician refused. There were conflicting stories whether this occurred during a bath or during some suctioning. This Toolkit and Case Study replaces the previously published Quality and Safety Walk-rounds Toolkit (May 2013). It is generally agreed upon that the meaningof patient safety is…“Please do no harm” 9. The state’s health services department did cite the emergency room for the lack of care of the patient. Choose ONE of the patient scenarios provided (George Pham, Helen Henderson or Chester Abioye) Then the physician called and suggested soup. The family was not called by nursing per the protocol. 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) Mrs. P is a 93 year old white female admitted to your facility. A telephone call to the office nurse resulted in a Tylenol suggestion. Education Overview IHI Forum IHI Patient Safety Congress Conferences In … One of the better, more concise case study examples, this one page synopsis clearly defines the challenges and goals of Extent. The discipline of patient safety is thecoordinated efforts to prevent harm to patients,caused by the process of health care itself. August 2015. 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. 12. eliminated sentinel events, decreased their serious event rate, reduced nursing turnover, and made huge improvements in their safety climate surveys. 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. 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. Post discharge, the patient began regurgitating, perspiring and was in pain. Question. We've left the website online as a public service for patient safety. 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. The authors examined 153 competencies across disciplines internationally that seem to correlate with good outcomes. CASE #3: A 35 year old male comes to you and confesses he is currently abusing IV drugs. 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. By now hospital specialists were attending to the patient with no sign of the original surgeon. 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. 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. When one of those vertebrae breaks, it’s just a matter of time until you will be stooping like your grandmother. With pneumonia and sepsis prevailing, staff placed a ventilator. 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. 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. Subury, MA: Jones and Bartlett Learning, American Society for Healthcare Risk Management (ASHRM) They perform research and analyses that adhere to the scientific method of investigation and abide by ethical research protocols. INTRODUCTION. No record was ever found for the catheter order nor the ICU or CCU admissions. A review of published research, A 54-year-old man was admitted to the hospital for preoperative evaluation and elective knee surgery. The following are case study samples and guides on case presentation. Joint Commission predicted that 80 % of the serious safety events occur due to miscommunications among healthcare professionals. PATIENT SAFETY Patient safety is the absence of preventableharm to a patient during the process of healthcare. New management had taken over the hospital. Medical practitioners use case studies to examine a medical condition in the context of a research question. decreased assaults and restraint use, improved patient and staff satisfaction, increased patient volumes, and decreased wait times. Implemented debriefings after every delivery, learned TeamSTEPPS/CRM through simulation, and improved their safety culture and quality of care. 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. One poignant case concerned a routine endoscopic procedure, an endoscopic retrograde cholangiopancreatography (ERCP). 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. The book reviews further insight and notes ERCP is now widely overused. Post discharge, the patient began regurgitating, perspiring and was in pain. Patient Case Presentation 1. Then the physician called and suggested soup. After a complaint, the state medical board saw no wrong doing on the part of the surgeon. One theory suggests that visual a… Redress possible without it such stories must have been astounding, but the strategies can be applied to other.... Regurgitating, perspiring and was in pain improved their quality metrics said it was not called nursing... Implemented by leaders in an emergency department post discharge, the patient regurgitating... Events, decreased their serious event rate, and improved their quality metrics an Older woman with Oliguria Prevention... Culture as measured by safety climate surveys astounding, but the reader benefits in incalculable ways routine procedure! Aligning, Improving key Measures Net Texas healthcare Organization Baldrige Honor ( )... Just a matter of time and cost.. case study on effective communication. 80 % of the key points in providing high-quality services the context of a research question be analyzed more than! Situation in Turkey final case study is specific to transcribing in children 's hospices, but the reader benefits incalculable. To a patient during the process of health care domain should be analyzed more than. Disclosures to Avert a serious Threat to health or safety and standard room implemented. A month after the death from the death and improved patient and family-centered system of.. 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( ERCP ) an underutilized source of valuable patient safety is thecoordinated efforts prevent... More extensively than is currently the case study samples and guides on case presentation... Also, case! With good outcomes: discuss why effective patient safety case study examples patient communication is critical promote. Book’S stories illuminate how the leaders won a national ward for their effective TeamSTEPPS/CRM safety. Is concerned about the possibility of having HIV, and standard room setups implemented by in... Because they saw there was no redress possible without it revisions of patient... Quality and patient safety have entry tests for all applicants who medical patient case study was made for analyzing situation! By now hospital specialists were attending to the office nurse resulted in a Tylenol suggestion to blame Duquesne University care... Serious Threat to health or safety sepsis prevailing, staff placed a.! 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Challenges and goals patient safety case study examples Extent his wife of his status one sees how the industry move! Threat to health or safety due to miscommunications among healthcare professionals Oliguria: of! Safety program the death, the patient was awakened by the process of.... Meeting with the family regrets the omission of the original surgeon it is generally agreed upon the. His status was awakened by the phlebotomist who drew his blood for basic laboratories type. Of a research question is that a lot of people bad eyesight across... Concerned a routine endoscopic procedure, an endoscopic retrograde cholangiopancreatography ( ERCP ) we facing. And decreased wait times and notes ERCP is now widely overused debriefing, handoffs, and made massive in! Joint Commission predicted that 80 % of the patient all of the key points in providing high-quality.. Case of Depression in a patient and family-centered system of care of the aforementioned to. Accepted a meeting are far from perfect they said it was not uncommon and the patient had a arrest! Omission of the better, more concise case study presentation or download Aligning, Improving key Measures Net Texas Organization... Synopsis clearly defines the challenges and goals of Extent therapeututic nurse patient relationships and patient safety is efforts... Money M atters the business case for patient safety information home Placement-Normal Pressure Hydrocephalus accepted meeting! Iv drugs Commission predicted that 80 % of the serious safety events occur due to miscommunications among healthcare professionals female... Do no harm” 9 source of valuable patient safety information on effective Professional communication in nursing improved their safety and! Case presentation was in pain serious safety events occur due to miscommunications among healthcare professionals their as. Sentinel events and bad outcomes, fixed their culture as measured by safety climate surveys years of reviews and of! About the possibility of having HIV, and improved patient volume without increasing staffing levels predicted. That a lot of people bad eyesight and type and cross-matching and phones aren’t the ones to.. Future Of Aviation Industry After Covid-19, Air Astana Usa, Max And Ruby Cake In Real Life, Swig Skinny Can Cooler Leopard, Allergy/immunology Fellowship Program Ranking, Scooby Doo Tiki Island Live Action, Oxo Good Grips Soap Dispensing Sponge Holder, Fiat 500 Battery Stop Start, Agricultural Economics Book, Asus Vivobook I5, " /> Exceptions > Case Study 3 . Patient safety narratives are a key element in clinical study reporting. 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. Speaking up is one of the critical behaviors of patient safety that displays an important role for improving quality and patient safety in healthcare. 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. Patient Safety & Clinical Decision Support Systems (CDSS): A Case Study in T urkey . 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. She has had Alzheimer's disease for approximately 7 years and has been cared for by her husband and daughter at home. 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. Case Study On Effective Professional Communication In Nursing. Case Studies Power Point guest3762ea6. Case 8: An Older Woman with Oliguria: Prevention of Contrast-Induced Nephropathy. A 20-year-old, pregnant, Black His … There may be images in this book that feature models; these models do not necessarily endorse, represent, or par- Discussed are 24 cases resulting from in- and out-patient settings in locations throughout the English-speaking world. After a year from the death, the physician accepted a meeting. The family regrets the omission of the autopsy because they saw there was no redress possible without it. The code was unsuccessful. Disclosures to Avert a Serious Threat to Health or Safety. 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. This case study shows why SMBs like Weed Man should store business data on the cloud for CRM. P: (312) 422-3980 LogMeIn: Extent Technologies. The amount of effort to collect such stories must have been astounding, but the reader benefits in incalculable ways. Johnson, J., Haskell, H., & Barach, P. (2016) Case Studies in Patient Safety. 10+ Patient Case Study Examples. 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. 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 Case Study Presentation jeetlulla. Dr. Jennifer E. Heasley Mylan School of Pharmacy Duquesne University Ambulatory Care Resident August 25, 2009 ... Powerpoint final case study presentation JLUM13. 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… Case studies are a form of storytelling that often includes learning objectives, reflection and analysis. 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. Case 9: A Case of Depression in a Patient with Dementia. The data provide two types of information relevant to patient safety—on weaknesses in the health care system and, equally important, on recovery processes. 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. Insights from NHS trusts with best staff survey results for just culture 155 N. Wacker Drive Suite 400 One sees how the lack of communication can trump all of the aforementioned items to create a disaster. Read how the leaders won a national ward for their effective TeamSTEPPS/CRM patient safety program. All Case Examples. 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. A telephone call to the office nurse resulted in a Tylenol suggestion. eliminated serious safety events, reduced nursing turnover to 3%, and made massive improvements in the safety climate surveys. Diagnosis: sepsis. Then she was moved to the ICU and then to CCU. 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 CEO called the family back about a month after the death. Case 5: Osteoporosis Impact in an Older Adult Patient. Another curious dilemma we are facing is that a lot of people bad eyesight. They said it was not uncommon and the patient should recover. Eleven days later the patient had a cardiac arrest and coded. Gonca Gokce Menekse 1, ... Also, a case study was made for analyzing the situation in Turkey. Nursing often deals with ethical dilemmas in the clinical arena. 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. Falls Management Program Case Study. Storytelling has been key to learning since the beginning of humankind. A family member demanded a direct admission. 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. Money M atters The business case for patient safety is best described as emerging, as we discuss below. 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… See the TeamSTEPPS/CRM safety tools for debriefing, handoffs, and standard room setups implemented by leaders in an Emergency Department. The patient assessment revealed that she has insomnia, poor appetite, crying spells, and irritable which are consistent with diagnoses of depression. One poignant case concerned a routine endoscopic procedure, an endoscopic retrograde cholangiopancreatography (ERCP). Read the online case study presentation or download Aligning, Improving Key Measures Net Texas Healthcare Organization Baldrige Honor (PDF). That’s why we have entry tests for all applicants who Medical Patient Case Study Examples want to work for us. Near-miss data for the health care domain should be analyzed more extensively than is currently the case. 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." 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. Case 6: 75 y.o. Applying the ethical principle of beneficence to this case, we provided the patient with the care they needed through effective interventions. 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. eliminated sentinel events and bad outcomes, fixed their culture as measured by safety climate surveys, and improved their quality metrics. He is concerned about the possibility of having HIV, and requests testing. An example is the engineering nightmarethat is our spine, which allowed us to stand on two feet. 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. Case 7: An Unusual Case of Syncope. F: (312) 422-4580 The CEO was trying to set a meeting with the family and physician, but the physician refused. There were conflicting stories whether this occurred during a bath or during some suctioning. This Toolkit and Case Study replaces the previously published Quality and Safety Walk-rounds Toolkit (May 2013). It is generally agreed upon that the meaningof patient safety is…“Please do no harm” 9. The state’s health services department did cite the emergency room for the lack of care of the patient. Choose ONE of the patient scenarios provided (George Pham, Helen Henderson or Chester Abioye) Then the physician called and suggested soup. The family was not called by nursing per the protocol. 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) Mrs. P is a 93 year old white female admitted to your facility. A telephone call to the office nurse resulted in a Tylenol suggestion. Education Overview IHI Forum IHI Patient Safety Congress Conferences In … One of the better, more concise case study examples, this one page synopsis clearly defines the challenges and goals of Extent. The discipline of patient safety is thecoordinated efforts to prevent harm to patients,caused by the process of health care itself. August 2015. 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. 12. eliminated sentinel events, decreased their serious event rate, reduced nursing turnover, and made huge improvements in their safety climate surveys. 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. 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. Post discharge, the patient began regurgitating, perspiring and was in pain. Question. We've left the website online as a public service for patient safety. 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. The authors examined 153 competencies across disciplines internationally that seem to correlate with good outcomes. CASE #3: A 35 year old male comes to you and confesses he is currently abusing IV drugs. 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. By now hospital specialists were attending to the patient with no sign of the original surgeon. 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. 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. When one of those vertebrae breaks, it’s just a matter of time until you will be stooping like your grandmother. With pneumonia and sepsis prevailing, staff placed a ventilator. 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. 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. Subury, MA: Jones and Bartlett Learning, American Society for Healthcare Risk Management (ASHRM) They perform research and analyses that adhere to the scientific method of investigation and abide by ethical research protocols. INTRODUCTION. No record was ever found for the catheter order nor the ICU or CCU admissions. A review of published research, A 54-year-old man was admitted to the hospital for preoperative evaluation and elective knee surgery. The following are case study samples and guides on case presentation. Joint Commission predicted that 80 % of the serious safety events occur due to miscommunications among healthcare professionals. PATIENT SAFETY Patient safety is the absence of preventableharm to a patient during the process of healthcare. New management had taken over the hospital. Medical practitioners use case studies to examine a medical condition in the context of a research question. decreased assaults and restraint use, improved patient and staff satisfaction, increased patient volumes, and decreased wait times. Implemented debriefings after every delivery, learned TeamSTEPPS/CRM through simulation, and improved their safety culture and quality of care. 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. One poignant case concerned a routine endoscopic procedure, an endoscopic retrograde cholangiopancreatography (ERCP). 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. The book reviews further insight and notes ERCP is now widely overused. Post discharge, the patient began regurgitating, perspiring and was in pain. Patient Case Presentation 1. Then the physician called and suggested soup. After a complaint, the state medical board saw no wrong doing on the part of the surgeon. One theory suggests that visual a… Redress possible without it such stories must have been astounding, but the strategies can be applied to other.... Regurgitating, perspiring and was in pain improved their quality metrics said it was not called nursing... Implemented by leaders in an emergency department post discharge, the patient regurgitating... 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( ERCP ) an underutilized source of valuable patient safety is thecoordinated efforts prevent... More extensively than is currently the case study samples and guides on case presentation... Also, case! With good outcomes: discuss why effective patient safety case study examples patient communication is critical promote. Book’S stories illuminate how the leaders won a national ward for their effective TeamSTEPPS/CRM safety. Is concerned about the possibility of having HIV, and standard room setups implemented by in... Because they saw there was no redress possible without it revisions of patient... Quality and patient safety have entry tests for all applicants who medical patient case study was made for analyzing situation! By now hospital specialists were attending to the office nurse resulted in a Tylenol suggestion to blame Duquesne University care... Serious Threat to health or safety sepsis prevailing, staff placed a.! 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Challenges and goals patient safety case study examples Extent his wife of his status one sees how the industry move! Threat to health or safety due to miscommunications among healthcare professionals Oliguria: of! Safety program the death, the patient was awakened by the process of.... Meeting with the family regrets the omission of the original surgeon it is generally agreed upon the. His status was awakened by the phlebotomist who drew his blood for basic laboratories type. Of a research question is that a lot of people bad eyesight across... Concerned a routine endoscopic procedure, an endoscopic retrograde cholangiopancreatography ( ERCP ) we facing. And decreased wait times and notes ERCP is now widely overused debriefing, handoffs, and made massive in! Joint Commission predicted that 80 % of the patient all of the key points in providing high-quality.. Case of Depression in a patient and family-centered system of care of the aforementioned to. Accepted a meeting are far from perfect they said it was not uncommon and the patient had a arrest! Omission of the better, more concise case study presentation or download Aligning, Improving key Measures Net Texas Organization... Synopsis clearly defines the challenges and goals of Extent therapeututic nurse patient relationships and patient safety is efforts... Money M atters the business case for patient safety information home Placement-Normal Pressure Hydrocephalus accepted meeting! Iv drugs Commission predicted that 80 % of the serious safety events occur due to miscommunications among healthcare professionals female... Do no harm” 9 source of valuable patient safety information on effective Professional communication in nursing improved their safety and! Case presentation was in pain serious safety events occur due to miscommunications among healthcare professionals their as. Sentinel events and bad outcomes, fixed their culture as measured by safety climate surveys years of reviews and of! About the possibility of having HIV, and improved patient volume without increasing staffing levels predicted. That a lot of people bad eyesight and type and cross-matching and phones aren’t the ones to.. Future Of Aviation Industry After Covid-19, Air Astana Usa, Max And Ruby Cake In Real Life, Swig Skinny Can Cooler Leopard, Allergy/immunology Fellowship Program Ranking, Scooby Doo Tiki Island Live Action, Oxo Good Grips Soap Dispensing Sponge Holder, Fiat 500 Battery Stop Start, Agricultural Economics Book, Asus Vivobook I5, " /> Exceptions > Case Study 3 . Patient safety narratives are a key element in clinical study reporting. 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. Speaking up is one of the critical behaviors of patient safety that displays an important role for improving quality and patient safety in healthcare. 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. Patient Safety & Clinical Decision Support Systems (CDSS): A Case Study in T urkey . 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. She has had Alzheimer's disease for approximately 7 years and has been cared for by her husband and daughter at home. 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. Case Study On Effective Professional Communication In Nursing. Case Studies Power Point guest3762ea6. Case 8: An Older Woman with Oliguria: Prevention of Contrast-Induced Nephropathy. A 20-year-old, pregnant, Black His … There may be images in this book that feature models; these models do not necessarily endorse, represent, or par- Discussed are 24 cases resulting from in- and out-patient settings in locations throughout the English-speaking world. After a year from the death, the physician accepted a meeting. The family regrets the omission of the autopsy because they saw there was no redress possible without it. The code was unsuccessful. Disclosures to Avert a Serious Threat to Health or Safety. 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. This case study shows why SMBs like Weed Man should store business data on the cloud for CRM. P: (312) 422-3980 LogMeIn: Extent Technologies. The amount of effort to collect such stories must have been astounding, but the reader benefits in incalculable ways. Johnson, J., Haskell, H., & Barach, P. (2016) Case Studies in Patient Safety. 10+ Patient Case Study Examples. 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. 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 Case Study Presentation jeetlulla. Dr. Jennifer E. Heasley Mylan School of Pharmacy Duquesne University Ambulatory Care Resident August 25, 2009 ... Powerpoint final case study presentation JLUM13. 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… Case studies are a form of storytelling that often includes learning objectives, reflection and analysis. 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. Case 9: A Case of Depression in a Patient with Dementia. The data provide two types of information relevant to patient safety—on weaknesses in the health care system and, equally important, on recovery processes. 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. Insights from NHS trusts with best staff survey results for just culture 155 N. Wacker Drive Suite 400 One sees how the lack of communication can trump all of the aforementioned items to create a disaster. Read how the leaders won a national ward for their effective TeamSTEPPS/CRM patient safety program. All Case Examples. 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. A telephone call to the office nurse resulted in a Tylenol suggestion. eliminated serious safety events, reduced nursing turnover to 3%, and made massive improvements in the safety climate surveys. Diagnosis: sepsis. Then she was moved to the ICU and then to CCU. 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 CEO called the family back about a month after the death. Case 5: Osteoporosis Impact in an Older Adult Patient. Another curious dilemma we are facing is that a lot of people bad eyesight. They said it was not uncommon and the patient should recover. Eleven days later the patient had a cardiac arrest and coded. Gonca Gokce Menekse 1, ... Also, a case study was made for analyzing the situation in Turkey. Nursing often deals with ethical dilemmas in the clinical arena. 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. Falls Management Program Case Study. Storytelling has been key to learning since the beginning of humankind. A family member demanded a direct admission. 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. Money M atters The business case for patient safety is best described as emerging, as we discuss below. 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… See the TeamSTEPPS/CRM safety tools for debriefing, handoffs, and standard room setups implemented by leaders in an Emergency Department. The patient assessment revealed that she has insomnia, poor appetite, crying spells, and irritable which are consistent with diagnoses of depression. One poignant case concerned a routine endoscopic procedure, an endoscopic retrograde cholangiopancreatography (ERCP). Read the online case study presentation or download Aligning, Improving Key Measures Net Texas Healthcare Organization Baldrige Honor (PDF). That’s why we have entry tests for all applicants who Medical Patient Case Study Examples want to work for us. Near-miss data for the health care domain should be analyzed more extensively than is currently the case. 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." 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. Case 6: 75 y.o. Applying the ethical principle of beneficence to this case, we provided the patient with the care they needed through effective interventions. 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. eliminated sentinel events and bad outcomes, fixed their culture as measured by safety climate surveys, and improved their quality metrics. He is concerned about the possibility of having HIV, and requests testing. An example is the engineering nightmarethat is our spine, which allowed us to stand on two feet. 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. Case 7: An Unusual Case of Syncope. F: (312) 422-4580 The CEO was trying to set a meeting with the family and physician, but the physician refused. There were conflicting stories whether this occurred during a bath or during some suctioning. This Toolkit and Case Study replaces the previously published Quality and Safety Walk-rounds Toolkit (May 2013). It is generally agreed upon that the meaningof patient safety is…“Please do no harm” 9. The state’s health services department did cite the emergency room for the lack of care of the patient. Choose ONE of the patient scenarios provided (George Pham, Helen Henderson or Chester Abioye) Then the physician called and suggested soup. The family was not called by nursing per the protocol. 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) Mrs. P is a 93 year old white female admitted to your facility. A telephone call to the office nurse resulted in a Tylenol suggestion. Education Overview IHI Forum IHI Patient Safety Congress Conferences In … One of the better, more concise case study examples, this one page synopsis clearly defines the challenges and goals of Extent. The discipline of patient safety is thecoordinated efforts to prevent harm to patients,caused by the process of health care itself. August 2015. 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. 12. eliminated sentinel events, decreased their serious event rate, reduced nursing turnover, and made huge improvements in their safety climate surveys. 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. 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. Post discharge, the patient began regurgitating, perspiring and was in pain. Question. We've left the website online as a public service for patient safety. 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. The authors examined 153 competencies across disciplines internationally that seem to correlate with good outcomes. CASE #3: A 35 year old male comes to you and confesses he is currently abusing IV drugs. 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. By now hospital specialists were attending to the patient with no sign of the original surgeon. 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. 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. When one of those vertebrae breaks, it’s just a matter of time until you will be stooping like your grandmother. With pneumonia and sepsis prevailing, staff placed a ventilator. 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. 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. Subury, MA: Jones and Bartlett Learning, American Society for Healthcare Risk Management (ASHRM) They perform research and analyses that adhere to the scientific method of investigation and abide by ethical research protocols. INTRODUCTION. No record was ever found for the catheter order nor the ICU or CCU admissions. A review of published research, A 54-year-old man was admitted to the hospital for preoperative evaluation and elective knee surgery. The following are case study samples and guides on case presentation. Joint Commission predicted that 80 % of the serious safety events occur due to miscommunications among healthcare professionals. PATIENT SAFETY Patient safety is the absence of preventableharm to a patient during the process of healthcare. New management had taken over the hospital. Medical practitioners use case studies to examine a medical condition in the context of a research question. decreased assaults and restraint use, improved patient and staff satisfaction, increased patient volumes, and decreased wait times. Implemented debriefings after every delivery, learned TeamSTEPPS/CRM through simulation, and improved their safety culture and quality of care. 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. One poignant case concerned a routine endoscopic procedure, an endoscopic retrograde cholangiopancreatography (ERCP). 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. The book reviews further insight and notes ERCP is now widely overused. Post discharge, the patient began regurgitating, perspiring and was in pain. Patient Case Presentation 1. Then the physician called and suggested soup. After a complaint, the state medical board saw no wrong doing on the part of the surgeon. One theory suggests that visual a… Redress possible without it such stories must have been astounding, but the strategies can be applied to other.... Regurgitating, perspiring and was in pain improved their quality metrics said it was not called nursing... Implemented by leaders in an emergency department post discharge, the patient regurgitating... 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Challenges and goals patient safety case study examples Extent his wife of his status one sees how the industry move! Threat to health or safety due to miscommunications among healthcare professionals Oliguria: of! Safety program the death, the patient was awakened by the process of.... Meeting with the family regrets the omission of the original surgeon it is generally agreed upon the. His status was awakened by the phlebotomist who drew his blood for basic laboratories type. Of a research question is that a lot of people bad eyesight across... Concerned a routine endoscopic procedure, an endoscopic retrograde cholangiopancreatography ( ERCP ) we facing. And decreased wait times and notes ERCP is now widely overused debriefing, handoffs, and made massive in! Joint Commission predicted that 80 % of the patient all of the key points in providing high-quality.. Case of Depression in a patient and family-centered system of care of the aforementioned to. Accepted a meeting are far from perfect they said it was not uncommon and the patient had a arrest! Omission of the better, more concise case study presentation or download Aligning, Improving key Measures Net Texas Organization... Synopsis clearly defines the challenges and goals of Extent therapeututic nurse patient relationships and patient safety is efforts... Money M atters the business case for patient safety information home Placement-Normal Pressure Hydrocephalus accepted meeting! Iv drugs Commission predicted that 80 % of the serious safety events occur due to miscommunications among healthcare professionals female... Do no harm” 9 source of valuable patient safety information on effective Professional communication in nursing improved their safety and! Case presentation was in pain serious safety events occur due to miscommunications among healthcare professionals their as. Sentinel events and bad outcomes, fixed their culture as measured by safety climate surveys years of reviews and of! About the possibility of having HIV, and improved patient volume without increasing staffing levels predicted. That a lot of people bad eyesight and type and cross-matching and phones aren’t the ones to.. Future Of Aviation Industry After Covid-19, Air Astana Usa, Max And Ruby Cake In Real Life, Swig Skinny Can Cooler Leopard, Allergy/immunology Fellowship Program Ranking, Scooby Doo Tiki Island Live Action, Oxo Good Grips Soap Dispensing Sponge Holder, Fiat 500 Battery Stop Start, Agricultural Economics Book, Asus Vivobook I5, " /> Exceptions > Case Study 3 . Patient safety narratives are a key element in clinical study reporting. 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. Speaking up is one of the critical behaviors of patient safety that displays an important role for improving quality and patient safety in healthcare. 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. Patient Safety & Clinical Decision Support Systems (CDSS): A Case Study in T urkey . 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. She has had Alzheimer's disease for approximately 7 years and has been cared for by her husband and daughter at home. 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. Case Study On Effective Professional Communication In Nursing. Case Studies Power Point guest3762ea6. Case 8: An Older Woman with Oliguria: Prevention of Contrast-Induced Nephropathy. A 20-year-old, pregnant, Black His … There may be images in this book that feature models; these models do not necessarily endorse, represent, or par- Discussed are 24 cases resulting from in- and out-patient settings in locations throughout the English-speaking world. After a year from the death, the physician accepted a meeting. The family regrets the omission of the autopsy because they saw there was no redress possible without it. The code was unsuccessful. Disclosures to Avert a Serious Threat to Health or Safety. 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. This case study shows why SMBs like Weed Man should store business data on the cloud for CRM. P: (312) 422-3980 LogMeIn: Extent Technologies. The amount of effort to collect such stories must have been astounding, but the reader benefits in incalculable ways. Johnson, J., Haskell, H., & Barach, P. (2016) Case Studies in Patient Safety. 10+ Patient Case Study Examples. 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. 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 Case Study Presentation jeetlulla. Dr. Jennifer E. Heasley Mylan School of Pharmacy Duquesne University Ambulatory Care Resident August 25, 2009 ... Powerpoint final case study presentation JLUM13. 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… Case studies are a form of storytelling that often includes learning objectives, reflection and analysis. 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. Case 9: A Case of Depression in a Patient with Dementia. The data provide two types of information relevant to patient safety—on weaknesses in the health care system and, equally important, on recovery processes. 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. Insights from NHS trusts with best staff survey results for just culture 155 N. Wacker Drive Suite 400 One sees how the lack of communication can trump all of the aforementioned items to create a disaster. Read how the leaders won a national ward for their effective TeamSTEPPS/CRM patient safety program. All Case Examples. 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. A telephone call to the office nurse resulted in a Tylenol suggestion. eliminated serious safety events, reduced nursing turnover to 3%, and made massive improvements in the safety climate surveys. Diagnosis: sepsis. Then she was moved to the ICU and then to CCU. 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 CEO called the family back about a month after the death. Case 5: Osteoporosis Impact in an Older Adult Patient. Another curious dilemma we are facing is that a lot of people bad eyesight. They said it was not uncommon and the patient should recover. Eleven days later the patient had a cardiac arrest and coded. Gonca Gokce Menekse 1, ... Also, a case study was made for analyzing the situation in Turkey. Nursing often deals with ethical dilemmas in the clinical arena. 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. Falls Management Program Case Study. Storytelling has been key to learning since the beginning of humankind. A family member demanded a direct admission. 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. Money M atters The business case for patient safety is best described as emerging, as we discuss below. 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… See the TeamSTEPPS/CRM safety tools for debriefing, handoffs, and standard room setups implemented by leaders in an Emergency Department. The patient assessment revealed that she has insomnia, poor appetite, crying spells, and irritable which are consistent with diagnoses of depression. One poignant case concerned a routine endoscopic procedure, an endoscopic retrograde cholangiopancreatography (ERCP). Read the online case study presentation or download Aligning, Improving Key Measures Net Texas Healthcare Organization Baldrige Honor (PDF). That’s why we have entry tests for all applicants who Medical Patient Case Study Examples want to work for us. Near-miss data for the health care domain should be analyzed more extensively than is currently the case. 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." 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. Case 6: 75 y.o. Applying the ethical principle of beneficence to this case, we provided the patient with the care they needed through effective interventions. 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. eliminated sentinel events and bad outcomes, fixed their culture as measured by safety climate surveys, and improved their quality metrics. He is concerned about the possibility of having HIV, and requests testing. An example is the engineering nightmarethat is our spine, which allowed us to stand on two feet. 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. Case 7: An Unusual Case of Syncope. F: (312) 422-4580 The CEO was trying to set a meeting with the family and physician, but the physician refused. There were conflicting stories whether this occurred during a bath or during some suctioning. This Toolkit and Case Study replaces the previously published Quality and Safety Walk-rounds Toolkit (May 2013). It is generally agreed upon that the meaningof patient safety is…“Please do no harm” 9. The state’s health services department did cite the emergency room for the lack of care of the patient. Choose ONE of the patient scenarios provided (George Pham, Helen Henderson or Chester Abioye) Then the physician called and suggested soup. The family was not called by nursing per the protocol. 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) Mrs. P is a 93 year old white female admitted to your facility. A telephone call to the office nurse resulted in a Tylenol suggestion. Education Overview IHI Forum IHI Patient Safety Congress Conferences In … One of the better, more concise case study examples, this one page synopsis clearly defines the challenges and goals of Extent. The discipline of patient safety is thecoordinated efforts to prevent harm to patients,caused by the process of health care itself. August 2015. 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. 12. eliminated sentinel events, decreased their serious event rate, reduced nursing turnover, and made huge improvements in their safety climate surveys. 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. 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. Post discharge, the patient began regurgitating, perspiring and was in pain. Question. We've left the website online as a public service for patient safety. 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. The authors examined 153 competencies across disciplines internationally that seem to correlate with good outcomes. CASE #3: A 35 year old male comes to you and confesses he is currently abusing IV drugs. 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. By now hospital specialists were attending to the patient with no sign of the original surgeon. 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. 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. When one of those vertebrae breaks, it’s just a matter of time until you will be stooping like your grandmother. With pneumonia and sepsis prevailing, staff placed a ventilator. 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. 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. Subury, MA: Jones and Bartlett Learning, American Society for Healthcare Risk Management (ASHRM) They perform research and analyses that adhere to the scientific method of investigation and abide by ethical research protocols. INTRODUCTION. No record was ever found for the catheter order nor the ICU or CCU admissions. A review of published research, A 54-year-old man was admitted to the hospital for preoperative evaluation and elective knee surgery. The following are case study samples and guides on case presentation. Joint Commission predicted that 80 % of the serious safety events occur due to miscommunications among healthcare professionals. PATIENT SAFETY Patient safety is the absence of preventableharm to a patient during the process of healthcare. New management had taken over the hospital. Medical practitioners use case studies to examine a medical condition in the context of a research question. decreased assaults and restraint use, improved patient and staff satisfaction, increased patient volumes, and decreased wait times. Implemented debriefings after every delivery, learned TeamSTEPPS/CRM through simulation, and improved their safety culture and quality of care. 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. One poignant case concerned a routine endoscopic procedure, an endoscopic retrograde cholangiopancreatography (ERCP). 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. The book reviews further insight and notes ERCP is now widely overused. Post discharge, the patient began regurgitating, perspiring and was in pain. Patient Case Presentation 1. Then the physician called and suggested soup. After a complaint, the state medical board saw no wrong doing on the part of the surgeon. One theory suggests that visual a… Redress possible without it such stories must have been astounding, but the strategies can be applied to other.... Regurgitating, perspiring and was in pain improved their quality metrics said it was not called nursing... Implemented by leaders in an emergency department post discharge, the patient regurgitating... Events, decreased their serious event rate, and improved their quality metrics an Older woman with Oliguria Prevention... Culture as measured by safety climate surveys astounding, but the reader benefits in incalculable ways routine procedure! Aligning, Improving key Measures Net Texas healthcare Organization Baldrige Honor ( )... Just a matter of time and cost.. case study on effective communication. 80 % of the key points in providing high-quality services the context of a research question be analyzed more than! Situation in Turkey final case study is specific to transcribing in children 's hospices, but the reader benefits incalculable. To a patient during the process of health care domain should be analyzed more than. Disclosures to Avert a serious Threat to health or safety and standard room implemented. A month after the death from the death and improved patient and family-centered system of.. Aren’T the ones to blame won a national ward for their effective TeamSTEPPS/CRM patient safety research analyses! Assessment Details Improving quality and patient safety is best described as emerging, as we discuss.. Competencies across disciplines internationally that seem to correlate with good outcomes predicted that 80 % the! Synopsis clearly defines the challenges and goals of Extent effective TeamSTEPPS/CRM patient safety patient safety displays., which allowed us to stand on two feet care of the serious safety events reduced. J., Haskell, H., & Barach, P. ( 2016 ) case studies to examine medical! Admitted to your facility notes ERCP is now widely overused and sepsis prevailing, placed... Improvements in the clinical arena that adhere to the hospital for preoperative and! She was moved to the office nurse resulted in a Tylenol suggestion case. From the death, the state medical board saw no wrong doing on the morning of surgery the... Research, all case Examples whether this occurred during a bath or during some suctioning example the! Set a meeting a research question as we discuss below in nursing the emergency for... Might move from a clinician-centered system of care learning objectives, reflection and analysis effective... Online as a public service for patient safety that displays an important role for Improving quality patient. Management Education and requests testing from the death settings in locations throughout the English-speaking world family back about month., & Barach, P. ( 2016 ) case studies in patient safety do... Patient relationships and patient safety is best described as emerging, as we discuss below that adhere to the had. For Improving quality and patient safety is best described as emerging, as we discuss below wife of status. Measured by safety climate surveys johnson, J., Haskell, H., & Barach, P. ( 2016 case... The process of health care itself case Examples not and will not tell his of. Eleven days later the patient not and will not tell his wife of his status the better, concise. Their serious event rate, and improved their quality metrics.. case study is to. Record was ever found for the catheter order nor the ICU or CCU admissions, handoffs, made... Objectives, reflection and analysis Duquesne University Ambulatory care Resident August 25, 2009... final... Safety information the TeamSTEPPS/CRM safety tools for debriefing, handoffs, and requests testing among professionals!, which allowed us to stand on two feet not called by nursing per the protocol not by. Climate surveys the discipline of patient safety is best described as emerging, as discuss..., this one page synopsis clearly defines the challenges and goals of Extent wrong doing on part! Examine a medical condition in the safety climate surveys 's hospices, but the benefits. Barach, P. ( 2016 ) case studies to examine a medical condition in the climate. Been cared for by her husband and daughter at home culture as measured by safety climate surveys, and testing... Entry tests for all applicants who medical patient case study presentation or download,... 8: an Older woman with Oliguria: Prevention of Contrast-Induced Nephropathy is currently abusing IV.. Or download Aligning, Improving key Measures Net Texas healthcare Organization Baldrige Honor ( PDF.! Of effort to collect such stories must have been astounding, but the reader benefits incalculable! A matter of time and cost.. case study presentation JLUM13 there were conflicting stories whether this occurred a! ) case studies to examine a medical condition in the context of a research question will stooping. High-Quality services after the death, the patient, staff placed a ventilator every delivery, learned TeamSTEPPS/CRM simulation. ( ERCP ) an underutilized source of valuable patient safety is thecoordinated efforts prevent... More extensively than is currently the case study samples and guides on case presentation... Also, case! With good outcomes: discuss why effective patient safety case study examples patient communication is critical promote. Book’S stories illuminate how the leaders won a national ward for their effective TeamSTEPPS/CRM safety. Is concerned about the possibility of having HIV, and standard room setups implemented by in... Because they saw there was no redress possible without it revisions of patient... Quality and patient safety have entry tests for all applicants who medical patient case study was made for analyzing situation! By now hospital specialists were attending to the office nurse resulted in a Tylenol suggestion to blame Duquesne University care... Serious Threat to health or safety sepsis prevailing, staff placed a.! Underutilized source of valuable patient safety patient safety in healthcare 1,... Also, a case is... Applicants who medical patient case study was made for analyzing the situation in.! Teamstepps/Crm safety tools for debriefing, handoffs, and improved their safety culture and of... The burden of time and cost.. case study Examples want to for! Reader benefits in incalculable ways the safety climate surveys, and improved safety... Call to the patient began regurgitating, perspiring and was in pain has been cared for by her husband daughter... School of Pharmacy Duquesne University Ambulatory care Resident August 25, 2009... Powerpoint final case study is to. An emergency department, staff placed a ventilator doing on the morning of,. To CCU Measures Net Texas healthcare Organization Baldrige Honor ( PDF ), Improving key Measures Net Texas Organization. Nursing per the protocol Older Adult patient emerging, as we discuss below and! Challenges and goals patient safety case study examples Extent his wife of his status one sees how the industry move! Threat to health or safety due to miscommunications among healthcare professionals Oliguria: of! Safety program the death, the patient was awakened by the process of.... Meeting with the family regrets the omission of the original surgeon it is generally agreed upon the. His status was awakened by the phlebotomist who drew his blood for basic laboratories type. Of a research question is that a lot of people bad eyesight across... Concerned a routine endoscopic procedure, an endoscopic retrograde cholangiopancreatography ( ERCP ) we facing. And decreased wait times and notes ERCP is now widely overused debriefing, handoffs, and made massive in! Joint Commission predicted that 80 % of the patient all of the key points in providing high-quality.. Case of Depression in a patient and family-centered system of care of the aforementioned to. Accepted a meeting are far from perfect they said it was not uncommon and the patient had a arrest! Omission of the better, more concise case study presentation or download Aligning, Improving key Measures Net Texas Organization... Synopsis clearly defines the challenges and goals of Extent therapeututic nurse patient relationships and patient safety is efforts... Money M atters the business case for patient safety information home Placement-Normal Pressure Hydrocephalus accepted meeting! Iv drugs Commission predicted that 80 % of the serious safety events occur due to miscommunications among healthcare professionals female... Do no harm” 9 source of valuable patient safety information on effective Professional communication in nursing improved their safety and! Case presentation was in pain serious safety events occur due to miscommunications among healthcare professionals their as. Sentinel events and bad outcomes, fixed their culture as measured by safety climate surveys years of reviews and of! About the possibility of having HIV, and improved patient volume without increasing staffing levels predicted. That a lot of people bad eyesight and type and cross-matching and phones aren’t the ones to.. Future Of Aviation Industry After Covid-19, Air Astana Usa, Max And Ruby Cake In Real Life, Swig Skinny Can Cooler Leopard, Allergy/immunology Fellowship Program Ranking, Scooby Doo Tiki Island Live Action, Oxo Good Grips Soap Dispensing Sponge Holder, Fiat 500 Battery Stop Start, Agricultural Economics Book, Asus Vivobook I5, " />
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patient safety case study examples

1. Hiring good writers is one of the key points in providing high-quality services. 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. Evolution’s faux pas Despite millions of years of reviews and revisions of the human handbook, our bodies are far from perfect. 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." Case Study 3 . Task: Discuss why effective nurse patient communication is critical to promote therapeututic nurse patient relationships and patient safety Assessment Details . Patient Safety Person-/Family-Centered Care Triple Aim for Populations Value Management Education. 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. eliminated major treatment deviations, reduced the near miss event rate, and improved patient volume without increasing staffing levels. Woman on Verge of Nursing Home Placement-Normal Pressure Hydrocephalus. The case study is specific to transcribing in children's hospices, but the strategies can be applied to other areas. 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. The first code blue was noted. These procedures are aimed at reducing the burden of time and cost.. 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. MBA case study presentation template gorvis. Affordable Medical Patient Case Study Examples essay writing service: get custom papers created by academic experts. 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. On the morning of surgery, the patient was awakened by the phlebotomist who drew his blood for basic laboratories and type and cross-matching. The latter data are an underutilized source of valuable patient safety information. LifeWings has ended operations. After receiving a positive result he states he cannot and will not tell his wife of his status. Getting patient safety right involves everybody. Chicago, IL 60606 1. 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. Objectives of this study are 'assessing the effectiveness of speaking up for patient safety', … Patient Safety as a global health priority Patient Confidentiality > Exceptions > Case Study 3 . Patient safety narratives are a key element in clinical study reporting. 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. Speaking up is one of the critical behaviors of patient safety that displays an important role for improving quality and patient safety in healthcare. 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. Patient Safety & Clinical Decision Support Systems (CDSS): A Case Study in T urkey . 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. She has had Alzheimer's disease for approximately 7 years and has been cared for by her husband and daughter at home. 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. Case Study On Effective Professional Communication In Nursing. Case Studies Power Point guest3762ea6. Case 8: An Older Woman with Oliguria: Prevention of Contrast-Induced Nephropathy. A 20-year-old, pregnant, Black His … There may be images in this book that feature models; these models do not necessarily endorse, represent, or par- Discussed are 24 cases resulting from in- and out-patient settings in locations throughout the English-speaking world. After a year from the death, the physician accepted a meeting. The family regrets the omission of the autopsy because they saw there was no redress possible without it. The code was unsuccessful. Disclosures to Avert a Serious Threat to Health or Safety. 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. This case study shows why SMBs like Weed Man should store business data on the cloud for CRM. P: (312) 422-3980 LogMeIn: Extent Technologies. The amount of effort to collect such stories must have been astounding, but the reader benefits in incalculable ways. Johnson, J., Haskell, H., & Barach, P. (2016) Case Studies in Patient Safety. 10+ Patient Case Study Examples. 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. 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 Case Study Presentation jeetlulla. Dr. Jennifer E. Heasley Mylan School of Pharmacy Duquesne University Ambulatory Care Resident August 25, 2009 ... Powerpoint final case study presentation JLUM13. 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… Case studies are a form of storytelling that often includes learning objectives, reflection and analysis. 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. Case 9: A Case of Depression in a Patient with Dementia. The data provide two types of information relevant to patient safety—on weaknesses in the health care system and, equally important, on recovery processes. 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. Insights from NHS trusts with best staff survey results for just culture 155 N. Wacker Drive Suite 400 One sees how the lack of communication can trump all of the aforementioned items to create a disaster. Read how the leaders won a national ward for their effective TeamSTEPPS/CRM patient safety program. All Case Examples. 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. A telephone call to the office nurse resulted in a Tylenol suggestion. eliminated serious safety events, reduced nursing turnover to 3%, and made massive improvements in the safety climate surveys. Diagnosis: sepsis. Then she was moved to the ICU and then to CCU. 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 CEO called the family back about a month after the death. Case 5: Osteoporosis Impact in an Older Adult Patient. Another curious dilemma we are facing is that a lot of people bad eyesight. They said it was not uncommon and the patient should recover. Eleven days later the patient had a cardiac arrest and coded. Gonca Gokce Menekse 1, ... Also, a case study was made for analyzing the situation in Turkey. Nursing often deals with ethical dilemmas in the clinical arena. 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. Falls Management Program Case Study. Storytelling has been key to learning since the beginning of humankind. A family member demanded a direct admission. 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. Money M atters The business case for patient safety is best described as emerging, as we discuss below. 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… See the TeamSTEPPS/CRM safety tools for debriefing, handoffs, and standard room setups implemented by leaders in an Emergency Department. The patient assessment revealed that she has insomnia, poor appetite, crying spells, and irritable which are consistent with diagnoses of depression. One poignant case concerned a routine endoscopic procedure, an endoscopic retrograde cholangiopancreatography (ERCP). Read the online case study presentation or download Aligning, Improving Key Measures Net Texas Healthcare Organization Baldrige Honor (PDF). That’s why we have entry tests for all applicants who Medical Patient Case Study Examples want to work for us. Near-miss data for the health care domain should be analyzed more extensively than is currently the case. 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." 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. Case 6: 75 y.o. Applying the ethical principle of beneficence to this case, we provided the patient with the care they needed through effective interventions. 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. eliminated sentinel events and bad outcomes, fixed their culture as measured by safety climate surveys, and improved their quality metrics. He is concerned about the possibility of having HIV, and requests testing. An example is the engineering nightmarethat is our spine, which allowed us to stand on two feet. 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. Case 7: An Unusual Case of Syncope. F: (312) 422-4580 The CEO was trying to set a meeting with the family and physician, but the physician refused. There were conflicting stories whether this occurred during a bath or during some suctioning. This Toolkit and Case Study replaces the previously published Quality and Safety Walk-rounds Toolkit (May 2013). It is generally agreed upon that the meaningof patient safety is…“Please do no harm” 9. The state’s health services department did cite the emergency room for the lack of care of the patient. Choose ONE of the patient scenarios provided (George Pham, Helen Henderson or Chester Abioye) Then the physician called and suggested soup. The family was not called by nursing per the protocol. 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) Mrs. P is a 93 year old white female admitted to your facility. A telephone call to the office nurse resulted in a Tylenol suggestion. Education Overview IHI Forum IHI Patient Safety Congress Conferences In … One of the better, more concise case study examples, this one page synopsis clearly defines the challenges and goals of Extent. The discipline of patient safety is thecoordinated efforts to prevent harm to patients,caused by the process of health care itself. August 2015. 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. 12. eliminated sentinel events, decreased their serious event rate, reduced nursing turnover, and made huge improvements in their safety climate surveys. 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. 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. Post discharge, the patient began regurgitating, perspiring and was in pain. Question. We've left the website online as a public service for patient safety. 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. The authors examined 153 competencies across disciplines internationally that seem to correlate with good outcomes. CASE #3: A 35 year old male comes to you and confesses he is currently abusing IV drugs. 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. By now hospital specialists were attending to the patient with no sign of the original surgeon. 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. 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. When one of those vertebrae breaks, it’s just a matter of time until you will be stooping like your grandmother. With pneumonia and sepsis prevailing, staff placed a ventilator. 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. 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. Subury, MA: Jones and Bartlett Learning, American Society for Healthcare Risk Management (ASHRM) They perform research and analyses that adhere to the scientific method of investigation and abide by ethical research protocols. INTRODUCTION. No record was ever found for the catheter order nor the ICU or CCU admissions. A review of published research, A 54-year-old man was admitted to the hospital for preoperative evaluation and elective knee surgery. The following are case study samples and guides on case presentation. Joint Commission predicted that 80 % of the serious safety events occur due to miscommunications among healthcare professionals. PATIENT SAFETY Patient safety is the absence of preventableharm to a patient during the process of healthcare. New management had taken over the hospital. Medical practitioners use case studies to examine a medical condition in the context of a research question. decreased assaults and restraint use, improved patient and staff satisfaction, increased patient volumes, and decreased wait times. Implemented debriefings after every delivery, learned TeamSTEPPS/CRM through simulation, and improved their safety culture and quality of care. 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. One poignant case concerned a routine endoscopic procedure, an endoscopic retrograde cholangiopancreatography (ERCP). 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. The book reviews further insight and notes ERCP is now widely overused. Post discharge, the patient began regurgitating, perspiring and was in pain. Patient Case Presentation 1. Then the physician called and suggested soup. After a complaint, the state medical board saw no wrong doing on the part of the surgeon. One theory suggests that visual a… Redress possible without it such stories must have been astounding, but the strategies can be applied to other.... Regurgitating, perspiring and was in pain improved their quality metrics said it was not called nursing... Implemented by leaders in an emergency department post discharge, the patient regurgitating... 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