Adverse Event Analysis

1033 words - 4 pages

The goal of patient safety is to prevent harm to patients Mitchell (n.d.). Patient safety in any health system is critical not only for the credibility of the system, but for patient trust and satisfaction as well. Adverse outcomes are defined as any injury or harm resulting from medical care (Watcher, 2008). Adverse outcomes can result in death and disability and cost the health system dearly. Bernard and Encinosa (2004) reported that in the U.S. it costs twice as much to care for patients that experienced adverse outcomes. The Institute of Medicine (IOM) (2000) reported that adverse outcomes cost the U.S. more than 16 billion dollars or 6% of total inpatient costs. Therefore, adverse events are costly both in terms of human life and fiscal resources.
In Dept Analysis of What Went Wrong / Issues that Impact Health Care Quality
In reviewing this case study, it is the writer’s opinion that poor communication between doctors treating this patient, limited patient assessment, provider bias/judgment, and inferior diagnostic procedures contributed to this adverse event.
Poor Communication
Ongoing, clear, open, and transparent communication between physicians seeing the same patient is critical since this can reduce medical errors, improve quality of care, and increase patient safety (Institute of Medicine, 2000). In this case study, no type of formal or informal communication between this patients’ PCP, internist, and the neurologist was reported.
In reviewing the medical care provided ,it seems that the patient’s previous medical history clouded her doctor’s decisions. Because of this, none of her doctors opted to dig deeper into other possible reasons for her daily headaches. Many factors that should have been considered as a part of this patient’s assessment such as blood pressure levels and prior head injuries were not evaluated during medical visits.
Provider Bias
It is the writer’s opinion that provider bias might have also contributed to this adverse event. This bias resulted from using previous medical history and provider judgment to diagnose the patient. Unfortunately, in the U.S. health care system many women are viewed as emotional, labeled or misdiagnosed by physicians (IOM, 2000; Agency for Healthcare Research and Quality, 2011). This bias interferes with a doctor’s motivation to complete comprehensive assessments or implement an aggressive treatment plans.
Lack of a Comprehensive Diagnostic Algorithm/ Treatment Plan
This patient was only referred for a CT scan when she was found unconscious in her car. Not once during her years of complains was she referred for a more comprehensive battery of diagnostic tests. Also, there was no report of her doctors completing biochemical tests, blood pressure checks, or questioning the patient about current or previous head injuries, all of which could have contributed to her headaches. These missteps all seemed to increase the risk for this patient and contributed to...

Find Another Essay On Adverse Event Analysis

Case Study Literature Review: Neonatal NEC and SimplyThick

4111 words - 16 pages both methods of adverse event reporting have positive and negative attributes it is still clear that some type of family involvement in the reporting systems would be beneficial in reducing adverse events for future patients. Conclusions and Future Implications to Practice The conclusions drawn from the analysis of this case study are that a variety of contextual factors played into the adverse event that occurred. Both system and human factors

Legal Case Study: 62 year old woman with skin cancer

1424 words - 6 pages regret to patient’s who experience an adverse event (O'Reilly, 2010). When an adverse event occurs, many times the patient and patient’s family are looking for several key elements - empathy, investigation, and resolution. Empathy allows the patient to receive emotional support from the healthcare providers. Investigation performs a root-cause-analysis to find out what happened and to avoid similar errors in the future. Resolution shares the results

Risk Management for Health Care Organization

1065 words - 4 pages The risk manager will adhere to the Joint commission requirements for reporting sentinel events for accredited hospitals. “Accredited hospital are to identify and respond to any sentinel event in a timely and through manner.”( Radtke, K., & Milton, C. (2003). The Requirements include a credible root analysis and the development of an action plan that reduces risk and improves patient safety measures. The process of the root analysis should find

Cardiovascular Effects of Diabetes Drugs

2104 words - 8 pages specifically for cardiac issues. Exclusion of the zero-event studies was necessary for this meta-analysis study design because the chosen endpoint for the study was a cardiac event. The inclusion of the trials with zero events could possibility result in different results. Excluding zero-event trials is particularly concerning when adverse event rates are being investigated, since it can lead to false or inflated concerns about patient safety.3 The

Risk Management

1729 words - 7 pages male singer Lam fell down from the stage and the doctor said he might become deaf. The insurance company will pay him HK$ 5 million .Property covers the event against the damage or theft of property. Work Cover is compulsory to protect the employees. Professional Indemnity covers Board members managing the event against claims. Another insurance that I think is very important when staging an outdoor event is the Adverse Weather Coverage. From the

Case Study Concerns an Infant that Died due to the Wrong Medication Treat

1482 words - 6 pages risk management should always proceed within the guidelines of their organization and abide by set of protocol and policies. In regards to an adverse event within the organization the following will be notified, the defense attorney and the risk manager will receive any copy of pertinent case law pertaining to the event. In notifying insurance carriers and defense lawyers for the organization, the risk manager will start preparation of reports of

Ketorolac Versus Opioids For Renal Colic

3890 words - 16 pages II-1 randomized controlled trials, and one is a level I meta-analysis. One of the studies addresses post-surgical pain treated with ketorolac and morphine, and the others relate to patients with renal colic presenting to emergency department. All trials compared opioids and NSAIDs to find out which is more effective in pain relief, has fewer adverse effects, and requires least rescue analgesia. Moreover, all studies had similar explicit inclusion

Corporate crime

3467 words - 14 pages is directly proportional to the stock price reactions to the allegation of corporate illegal activities. H1*: The adverse implication of firm’s reputation is directly proportional to the stock price reactions to the allegation of corporate illegal activities. 3.6 Conclusion This chapter presents the overall methodology which starts from the entire event window design, sample size (selected corporation

Annie and Methotrexate

2193 words - 9 pages ). Benefit-risk analysis of adalimumab versus methotrexate and Placebo in the treatment of moderate to severe psoriasis: comparison of adverse event- Free response days in the champion trial. Journal of the American Academy of Dermatology, 63(6), 1011-1018. doi: 10.1016/j.jaad.2009.12.029 O’Rielly, D.D., & Rahman, P. (2011). Pharmacogentics of psoriasis. Pharmacogentics 12(1), 87-101. doi: 10.22171pgs.10.166 Naik, S. (2011). Towards

Accident Causation Theory

2464 words - 10 pages the clinical research on Reasons theory was done in health care facility where many unintended harm to patient is being caused by health worker(MALCOLM ELLIOTT, 2012). More than half of it could be prevented. So using this model, a constructive way of underpinning the cause of adverse event is done. Reasons model is recommended as framework for adverse events analysis as it focuses on latent condition and factors that clinician tried to do their

In What Ways Can A Critical Analysis Of ‘Management’ Be Beneficial For The Society?

2205 words - 9 pages organisation yet keeping efficiency and effectiveness at its core (Hodson R, Roscigno V et al, 2013.). Thus his analysis is not as beneficial to society today as it was during his time. Zygmunt Bauman on management Bureaucracy and its features of rational behaviour was a key element when it came to a horrifying event. The only event, which has shocked the society, can be argued to be the Holocaust. Bauman analyses the Holocaust and finds

Similar Essays

Hospital Risk Management Essay

1038 words - 4 pages significant chance of a serious adverse outcome. Any time a sentinel event occurs, the health care organization is expected to complete a thorough and credible root cause analysis, implement improvements to reduce risk, and monitor the effectiveness of those improvements. The root cause analysis is expected to drill down to underlying organization systems and processes that can be altered to reduce the likelihood of a failure in the future and to

Medication Management For Older Adults Essay

1156 words - 5 pages practices and documentation. Patient and caregiver education is central to preventing ADE’s, along with follow up and monitoring. Zwicker D, Fulmer T. (2012) guideline on preventing adverse drug reactions is comprehensive, and I did not identify any missing topic. The research method for Zwicker D, Fulmer T. (2012) is a meta-analysis with systematic review. This was completed by doing a hand search of published literature using Cochrane

Polypharmacy In Older Adults Essay

1242 words - 5 pages manage disease such as diabetes, heart failure and chronic obstructive pulmonary disease (Kaufman, 2011, p. 49). Polypharmacy is associated as a major factor placing older adults at risk for an adverse drug event. As the number of medications increase, the need for monitoring becomes much more crucial. When there is a breakdown in proper monitoring, the older adult is significantly placed at a higher risk for negative health outcomes due to

Patient Safety And Risk Management Essay

2152 words - 9 pages starting point on areas that may need changing. There are three areas to a root cause analysis of the adverse event which can enable the investigator to; 1) isolate the circumstances that increased the risk of an accident or incident from occurring; 2) determine who or what was involved in the situation; and (3) assess whether the facility might have control over the causes of the event (William, 2008). Using a report outline can help gather