Introduction
For many years, the operating room (OR) has been a significant source of malpractice liability. Plaintiff attorneys have been quick to exploit the vulnerability of an anesthetized patient, harmed by a medical error that lay persons have no difficulty understanding, like surgery on the wrong limb. The irony of the analysis which has been so effective in the courtroom is that the function of the OR is anything but simple.
The OR is an alien environment to all except the health care professionals who practice there. The OR has unique requirements for physical infrastructure, analogous to the intensive care area, to make certain procedures run safely. The OR staff is composed of many highly specialized professionals who bring unique skill sets to the care of increasingly acute patients. The continuum of care issues that risk managers must deal with include informed consent, preoperative preparation, operative procedure, wrong-site surgery, immediate postoperative care, and many risk situations associated with these broad areas.
Root Cause Analysis (RCA) is a key element in organizational learning. RCA identifies the direct cause of adverse events but also brings to light the indirect causes and latent errors. The Joint Commission requires that healthcare organizations select one high-risk process each year and subject it to failure mode. RCA is utilized for those steps in the system where failure is critical to the outcome, thereby identifying possible negative events.
Aligned to ULO(s)
ULO4: Summarize a medical error event and its impact on internal and external stakeholders (CLO1, CLO3)
ULO5: Examine the concept of disclosure and apology (CLO4)
ULO6: Explore the use of a hospital medical equipment management plan (CLO5)
ULO7: Discuss the importance of adequate supervision of residents by the supervising attending physicians (CLO4)
ULO8: Prepare a Root-Cause Analysis and an Action Plan to manage risk of an adverse event (CLO1, CLO3, CLO4)
Requirements
The submission should reflect higher-level cognitive processing (analysis, synthesis, and evaluation), which is essential for someone being prepared to serve in an operational capacity within the healthcare and related industry.
To earn the maximum number of points, the submission should reflect college-level execution with clear evidence of critical thinking, synthesis of relevant information from credible sources, and clear mastery of the concepts necessary to successfully execute each component of the assignment.
This business letter with recommendation should not exceed two (2) pages in length, excluding the title and reference list pages, and explicitly address all required components of this assignment.
If more pages would be needed, then the business letter can be accompanied by an attachment to add more detailed information.
The business letter with recommendations should be prepared as a practical business deliverable (single-spaced) and include at least three (3) references of credible or peer-reviewed sources to support any suppositions and recommendations.
The in-text citations and the list of references must adhere to the APA writing style (7th ed.).
For the Root Cause Analysis and Action Plan, use the actual table form the Joint Commission RCA Framework.
Finally, the document should be prepared as a Microsoft Word document and uploaded to Submit Assignment.
Refer to Assignments and Grading for more information.
Resources
The Joint Commission. (2017). Framework for Conducting a Root Cause Analysis and Action Plan.
(Links to an external site.)
Retrieved from http://www.jointcommission.org/framework_for_conducting_a_root_cause_analysis_and_action_plan/
Due Date
By Sunday at 11:59 P.M., CT.
Case Study
A 61-year-old female was admitted for a planned total right knee replacement. The patient’s bones were more dense than normal because she was large and her knee joint was arthritic. The supervising attending surgeon allowed a resident to perform most of the procedure. When the resident used a saw to cut a notch in the femur (thigh bone, the strongest and the longest bone in the body), he encountered more resistance than usual. The saw overly vibrated, and the resident accidentally removed an extra amount of bone from the femur and severed the patient’s posterior cruciate ligament. He used the largest available knee implant available in the operating room, though it looked like a larger implant would have fit better.
After the surgery, no explanation was offered to the patient or her husband about the reasons why the surgery took longer or about the complications that had been encountered. The attending surgeon documented in the operative note that there was no functioning posterior cruciate ligament, however, did not state the reason.
One month later, the patient’s knee dislocated. According to an X-ray the implant was malaligned and somewhat small. For a revision surgery, the same attending surgeon used a larger implant in order to stabilize the knee. However, postoperatively the patient still experienced moderate instability of her ligaments and proceeded with physical therapy.
One year later, the same orthopedic surgeon replaced the patient’s other (left) knee; and the surgery was successful. However, on the third day after the surgery, the patient’s right knee dislocated again. In order to stabilize the right knee, the surgeon performed another revision and used a larger implant than the previous one.
For two years, the patient did well being extremely careful; and then experienced dislocation of her right knee again. Because the patient’s surgeon was on vacation, a different orthopedic surgeon evaluated her case. This surgeon showed on X-ray that too much bone was removed in the original surgery of the patient’s right knee. He explained to the patient that as a result her ligaments do not function properly, which leads to repetitive dislocations. One more total right knee replacement was successful; however, the patient is unable to climb stairs, cannot stand for long periods, and has constant pain. The prognosis is that it is likely that, in the future, she will need her right knee fused, eliminating the joint itself.
Questions
Prepare a concise summary of the medical error event and discuss the impact this event had on internal and external stakeholders.
Discuss the problem of unavailability of the appropriate medical equipment in the operating room in the scenario (proper size knee implant). Find on the Internet an example of a hospital medical equipment management plan (MEMP). Discuss: which hospital MEMP you found; the scope of the program; the employee titles responsible for the maintaining the MEMP.
Discuss the issue of inadequate supervision of the resident by the supervising attending surgeon in the operating room in the scenario. Did the resident surgeon have the necessary skills to operate on the high complexity case? Find on the Internet an example of hospital guidelines for supervising residents in a department of surgery. Discuss: which hospital guidelines you found; the purpose of the guidelines; scope of the guidelines procedures; supervision of surgical residents in the operating room.
Discuss the issue of not disclosing surgical complications in the scenario. Define and discuss the concept of “Disclosure and Apology” within the context of risk management. Provide your recommendations for this case scenario on creating a culture of transparency to inform patients of harmful medical errors.
Discuss the Root-Cause Analysis technique. Is it used before or after an adverse event occurs?
Download the Framework for Conducting a Root Cause Analysis template from the Joint Commission website. Use the analysis questions in the template (pp.3-11) to prepare a Root-Cause Analysis of the adverse event in the scenario. Use the organization plan of action / risk reduction strategies in the template (p.12) to prepare an Action Plan to manage risk of an adverse event in the scenario. Consider how this situation could be avoided. Provide at least three recommendations for improvement.
Optional Resources:
Additional Resources (Optional)
Alverson, D. C. (2014). When does telemedicine become a standard of care?
(Links to an external site.)
The SciTech Lawyer, 10(3), 1-3. Retrieved from https://www.americanbar.org/content/dam/aba/publications/scitech_lawyer/2014/spring/when_does_telemedicine_become_a_standard_of_care.pdf
Daniel, H., Snyder, S. (2015, November 17). Policy recommendations to guide the use of telemedicine in primary care settings: An American College of Physicians position paper.
(Links to an external site.)
Annals of Internal Medicine. Retrieved from http://annals.org/aim/fullarticle/2434625/policy-recommendations-guide-use-telemedicine-primary-care-settings-american-college
Federation of State Medical Boards. (2014). Model policy for the appropriate use of telemedicine technologies in the practice of medicine.
(Links to an external site.)
Retrieved from https://www.fsmb.org/siteassets/advocacy/policies/fsmb_telemedicine_policy.pdf
Natoli, C. M. (2009). Summary of findings: Malpractice and telemedicine.
(Links to an external site.)
In Center for Telehealth and e-Health Law. Retrieved from http://www.ctel.org/research/Summary%20of%20Findings%20Malpractice%20and%20Telemedicine.pdf
Health Privacy Project. (2018). Health privacy stories.
(Links to an external site.)
Retrieved from https://www.cdt.org/files/healthprivacy/20080311stories.pdf
The Joint Commission. (2017). Framework for Conducting a Root Cause Analysis and Action Plan.
(Links to an external site.)
Retrieved from http://www.jointcommission.org/framework_for_conducting_a_root_cause_analysis_and_action_plan/
Morgan, J. (n.d.). The 5 types of organizational structures: Part 1, the hierarchy.
(Links to an external site.)
Retrieved from https://www.forbes.com/sites/jacobmorgan/2015/07/06/the-5-types-of-organizational-structures-part-1-the-hierarchy/#4742eb975252
Smithson, K. & Baker, S. (2007). Medical staff organizations: A persistent anomaly.
(Links to an external site.)
Health Affairs, 26(1). Retrieved from https://www.healthaffairs.org/doi/full/10.1377/hlthaff.26.1.w76
The liability of negligent hiring
(Links to an external site.)
(n.d.). Retrieved from http://ptresearchinc.com/resources/downloads/Negligent%20Hiring.pdf
Writing, A. (2018). Different types of organizational structure.
(Links to an external site.)
Retrieved from https://smallbusiness.chron.com/different-types-organizational-structure-723.html
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