Brianna Cohen's Case Study
Brianna Cohen, a young girl who was recovering from a bone marrow transplant but died due to an improperly mixed intravenous solution that caused her heart to stop, is the subject of the case study. The girl was given a potassium solution that was five times the recommended dose. The child displayed rising potassium levels in her subsequent checkups, but the health practitioners refused to change the amount of potassium in her solutions.
Failure of the System
In the Swiss cheese model, every step in a process has a chance for failure. For a catastrophic error to occur, like the one the Cohens experienced, the holes need to align each other in the process allowing for the hazard pass and the defense to be defeated (Perneger, 2005). According to Dr. Dover, the director of the Hopkins Children's Center, the process for delivering Total Parenteral Nutrition (TPN) starts with its computation at the Children's Center. Then it is faxed to the infusion pharmacy of home care groups. The technician prepares the solution assisted by a pharmacist who uses a built-in redundancy designed to eliminate the errors. The infusion pharmacy then supplies the TPN to all Hopkins patients. To assess the system failure, Dr. Dover describes that they checked the computation and found that it had no errors and faxed it to the infusion pharmacy. During Brianna checkups and after noting that the potassium levels were on the rise, their discharge statement indicated that the Child was to use a new solution that contained half the amount of potassium administered initially. However, the communication didn't suggest that the adjustments were a high priority. Therefore, the homecare did not deliver the new solution to the Cohens. As a result, the patient succumbed. The system failure occurred in the communication between caregivers. The Hopkins system stepped up its efforts to improve patients' safety by computerized order systems, and frequent rigorous medical checkups but failed on its communication between caregivers.
The Leadership Structure of the Healthcare System
The culture in this care setting required that the infusion pharmacy of the home care group receive solution formulas from the main hospital, John Hopkins Children's Center. The team then provides medication, supplies, and staff to Hopkins outpatients. In the home care group, there is a technician who prepares the solution and a pharmacist who monitors to ensure that the process is correct. The leadership structure of the healthcare system is that; the whole system is under the authority of the director of the Hopkins Children's Center. The patient's doctor follows as he is the one that oversees the treatment of the patient, then the president of the home care group who supervises the functions that take place at the local scale. The leadership structure comes out through the process in which the hospital released their statement. Consequently, the director was the one that answered all the questions raised. He was the one that was authorized to answer the questions and make comments on behalf of the medical facility. The oncologists and the president for the homecare declined interviews and directed them to the director as they had no authority to speak on behalf of the medical facility.
Communication and Teamwork
The case study reveals that simple human factors such as communication in a work environment are essential in ensuring patients' safety. Teamwork is also beneficial in achieving an institution's goal. For instance, Brianna had successfully undergone surgery, radiation, and chemotherapy. She also received a bone marrow transplant lucky and was in the process of recuperating. Her discharge signified hope for her family but due to poor communication and negligence by some of the team members all the efforts to assist the child halted. There was poor communication as the primary hospital did not communicate the urgency to change the solution. It was negligence on the part of the home care staff. First, they decided to prepare the solution using their hands instead of the machine. Secondly, they assumed that the original solution posed no risk to the child and advised the father to use it without confirming with the doctor. This case also highlights the vulnerability that exists between handoffs. It could be a case of the medical practitioners assuming the other person knows. Even handing over information without specific guidelines and the other health caregiver seeking clarification could lead to distortion of information. For example, in this case study, it was difficult to identify precisely why the system failed as everybody claimed they did as per the standard procedure.
Apology Violation and Patient Engagement
Sometimes medical errors happen such as in Brianna's case. When they occur, they have adverse effects on the patient and the physician. One way in which health caregivers respond to errors is through an apology. Apology statement includes; acknowledging that a mistake occurred, taking responsibility and expressing regret for the consequences (Robbennolt, 2009). For instance, the director of John Hopkins Children's Hospital apologized to the family by acknowledging that an error in the system caused the death of Brianna. He also made a statement to the effect that the hospital takes responsibility for the damage caused and even promised the family that the facility is doing all that it can to ensure that no other child succumbs to such an error. Apologies are essential as they are therapeutic to the affected families, improves trust and relationships and also reduce the risk of medical malpractice lawsuit (Robbennolt, 2009).
Patient Safety Tools
The article displays the use of several patient safety tools; AHRQ Patient Safety Culture Surveys which includes personnel administered surveys designed explicitly for itinerant care givers in nursing homes, medical facilities and community pharmacies (Agency for Healthcare Research and Quality, 2016). Another tool used is The Guide to Patient and Family Engagement in Hospital Quality and Safety it contains an implementation handbook to guide patients, clinicians, and families (Agency for Healthcare Research and Quality, 2016). There are also other tools that oat to be used in the case study such as; The Medical At Transitions And Clinical Handoff (MATCH). The tool looks at the strategies that can assist the hospital in the reconciliation of patients records as they move across different health systems (Agency for Healthcare Research and Quality, 2016).
There is evidence of bias in the case. First, the suppliers at the homecare were biased in their decision not to deliver the solution that night. It could be because the decision favored their schedule. On the other hand, the decision could be stability biased. The health caregivers did not see any cause for alarm since the child did not show any adverse symptoms. Therefore, they decided to wait and deliver the solution the next day.
References
Agency for Healthcare Research and Quality. (2016, May). AHRQ Patient Safety Tools and Resources. Retrieved November 21, 2017, from http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/pstools/index.html
Niedowski, E. (2003). Medical Error Kills Hopkins Cancer Patient. The Baltimore Sun.
Perneger, T. V. (2005). The Swiss cheese model of safety incidents: are there holes in the metaphor? BioMed Central. Retrieved November 21, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1298298/
Robbennolt, J. K. (2009, February). Apologies and Medical Error. Clinical Orthopaedics and Related Research, 376-382. Retrieved November 21, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628492/
