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.
Assessment
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...

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