How Did Organizational Influence, Unsafe Supervision, Etc. Cause This Error To Happen? How Will You Avoid Making Such An Error In The Future? Instructions
Systems errors, human errors, and process issues can lead to sentinel events in a hospital. Create your initial post and then use the response prompts to reply to the scenarios or examples created by at least two peers.
Initial Post
In 200–250 words, construct a scenario or example of an error that would result in harm to a patient for your initial post. This scenario or example can be something you have witnessed or a hypothetical example of a sentinel event. DO NOT post the same scenario or example as a peer.
Scenario:
In a hospital, a patient was scheduled for a surgical procedure. The surgical team had completed the necessary pre-operative checks and procedures, including verifying the patient’s identity, confirming the surgical site, and obtaining informed consent. However, during the surgery, the surgeon realized that the wrong procedure was being performed on the patient. Upon reviewing the patient’s chart, it was discovered that there was a mix-up in the patient’s identification, and the wrong patient had been brought to the operating room. This error resulted in harm to the patient, including unnecessary surgery, prolonged hospitalization, and potential psychological trauma.
Organizational influence, unsafe supervision, and communication breakdowns are factors that could have contributed to this error. For example, the hospital may not have had proper policies and procedures in place for patient identification and verification. Additionally, the surgical team may not have received adequate training on these procedures or may not have followed them correctly. Furthermore, inadequate supervision by the surgical team leader may have also contributed to this error.
To avoid making such an error in the future, hospitals should prioritize patient safety by implementing robust policies and procedures for patient identification and verification. The surgical team should be adequately trained and supervised to ensure that they follow these procedures correctly. Additionally, effective communication between the surgical team members, including clear verbal confirmation of patient identification and surgical site, should be encouraged. By prioritizing patient safety, hospitals can reduce the likelihood of errors occurring and prevent potential harm to patients.
