Who was affected and how did it influence quality service delivery at this facility?

The following is a brief introduction to the topic:

Healthcare is a complicated system that demands attention to details and adaptability to changes. Medical errors are a major problem in the healthcare industry, despite efforts to improve quality and safety. The report provides a case study of an actual healthcare mistake that negatively affected patient safety. It also includes an evaluation and improvement recommendations.

Situation Description

This incident occurred at a large teaching facility located in an urban area. The error occurred in the hospital’s emergency department, where a patient was admitted with chest pain and shortness of breath. A physician examined the patient and ordered an electrocardiogram. A communication breakdown prevented the ECG from being performed.

A pulmonary embolism was diagnosed on the X-ray of the patient’s chest. The patient’s condition worsened, and they were transferred to the intensive care unit (ICU) for further treatment. Unfortunately, the delay in diagnosis and treatment resulted in the patient’s death.

Quality Service Delivery

The error made a major impact on the quality of service provided at the hospital. The patient’s death not only had a profound effect on their family but also on the hospital staff. The hospital’s reputation was tarnished, and patient trust in the hospital was undermined. This incident can also lead to staff burnout, and lower job satisfaction. These factors may ultimately impact the quality of patient care.

Handling an Event

The hospital’s leaders and internal stakeholders took this event very seriously and conducted an internal investigation to identify the root cause of the error. It was revealed in the investigation that the ECG had not been performed because of a failure to communicate between the doctor and nursing staff. The hospital’s leaders implemented several changes, including improving communication protocols and increasing training for staff on patient safety and quality improvement.

External stakeholders, including the patient’s family and regulatory bodies, were also notified of the incident and the steps being taken to address the issue. The hospital’s leaders recognized the importance of transparency and worked to maintain open lines of communication with all stakeholders.

Recommended Improvements

In order to avoid this happening again, hospital staff should follow the recommendations below:

1. Standardize communication protocol: In order to prevent communication breakdowns the hospital must develop communication protocols which clearly define the roles and responsibilities of healthcare providers.
2. Staff training in patient safety should be improved: It is important to increase staff training to improve patient safety. This will ensure all employees have the necessary knowledge and skills to detect and eliminate potential errors.
3. Implementing a Quality Improvement Program: It is important to implement a program to improve quality. This will help identify systemic problems that could contribute to mistakes. The program must include regular evaluation of the patient’s outcomes, as well as feedback from both staff and patients.
4. Develop a Culture of Safety: In order to promote a culture for safety, hospitals should encourage communication with patients and staff as well as the reporting of any errors. It is important that staff feel free to make mistakes without worrying about retaliation.

You can also read our conclusion.

In healthcare, medical mistakes are a major problem. Healthcare organizations must take steps to avoid them. This report illustrates the value of a safety culture, effective communication and staff training in order to prevent errors. The hospital will be able to improve both patient safety and care quality by implementing these recommendations.