Part 1 (10 pts):Teams play a major role regardless of the setting. In health care, teams are formed to focus on issues that are in need of improvement, they need to have input from a variety of stakeholders. For this assignment, select a team that is of interest to you – describe the team and their mission – what is the role of the leaders/coaches, in your opinion, what makes this team successful? Are there any opportunities for this team to improve -what are they? What are some of the key lessons learned from observing this team and how you will be able to apply them to your assigned class team?
Part 2 (20 pts):RCA (Root Cause Analysis) is an accident investigation technique undertaken to find and fix the fundamental causes of an adverse event. It is similar to any improvement method that follows the steps of the Plan-Do-Study-Act cycle.Read the description of the wrong-site surgery event in critical concept 8.2 and the root causes identified by the team who conducted the RCA (below). Conduct a literature review and Internet search for corrective actions aimed at preventing wrong-site surgeries. Which of these actions would help prevent a similar event from occurring at the hospital described in critical concept 8.2?
Critical Concept 8.2
A 62-year-old man was scheduled to undergo an arthroscopy procedure. Three weeks before the surgery, the orthopedic clinic telephoned the hospital to sched- ule the man’s procedure. At that time, the front-office staff in the clinic mistak- enly scheduled a left-knee arthroscopy instead of a right-knee arthroscopy. The surgery scheduling clerk at the hospital faxed a surgery confirmation form to the clinic. Per hospital policy, the clinic is expected to review the information on the form, verify the accuracy, and fax the signed confirmation back to the hospital. The clinic staff were busy and did not fax the confirmation back. On the day of the surgery, the patient’s paperwork indicated that the surgery was to be performed on his left knee, per the original phone call from the clinic. The surgery schedule, a document used to plan the day’s activities in the oper- ating area, also indicated that the patient was to have a left-knee arthroscopy. The man was taken to the preoperative holding area, where a nurse spoke with him about his upcoming procedure. Relying only on the surgery schedule, the nurse asked the patient to confirm that he was having an arthroscopy on his left knee. The man told the nurse that he had been experiencing pain in both knees and that he’d eventually need procedures on both of them. He thought he was scheduled for surgery on his right knee that day but figured that perhaps the doctor had decided to operate on his left knee instead. The nurse did not read the history and physical examination report that the patient’s doctor had brought to the hospital that morning. If she had read this report, she would have noticed that it indicated the patient was to have surgery on his right knee that day. The anesthesiologist examined the patient in the preoperative holding area. When asked about the procedure, the man was confused about which knee was to be operated on that day. The anesthesiologist wrote “knee arthroscopy” in his notes in the patient’s record. The patient was taken into the operating room, where the surgeon was waiting. The surgeon spoke with the patient about the upcoming procedure on his right knee, and the patient signed a consent form indicating that surgery was to be performed on the right knee that day. The sur- geon marked his initials on the man’s right knee in ink to designate the surgery site. The anesthesiologist and scrub nurse readied the room for the procedure. The patient was anesthetized and fell asleep. Thinking the man was having surgery on his left knee, the nurse placed a drape over his right knee, not notic- ing the surgeon’s initials. The left knee was placed in the stirrup and prepped for the procedure. The nurse then asked everyone in the room to confirm that the man was the correct patient and that he was having an arthroscopy on his left knee. Everyone in the room said “yes” except the surgeon, who was busy pre- paring for the procedure. Distracted, he nodded his head in agreement. The nurse documented on the preoperative checklist that the patient’s identity, procedure, and surgery site had been verified. The surgeon performed the arthroscopy on the knee that had been prepped— the left one. When the patient awoke in the surgical recovery area, he asked the nurse why he felt pain in his left knee and told her the procedure should have been performed on his right knee. The nurse notified the surgeon, who immedi- ately informed the patient and his family about the mistake.
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Teamwork and RCA (Root Cause Analysis) are two important aspects in healthcare that contribute to achieving better patient outcomes and improvement in healthcare processes. In this assignment, we will explore the role of teams in healthcare, specifically focusing on a team of interest and analyzing their mission, leadership, success factors, opportunities for improvement, and lessons learned. Additionally, we will conduct a literature review and internet search to identify corrective actions that can help prevent wrong-site surgeries, using a real-life case as an example.
The team I have chosen to analyze is the Interdisciplinary Care Team at a local primary care clinic. This team is comprised of physicians, nurses, pharmacists, social workers, and other healthcare professionals. Their mission is to provide comprehensive and coordinated care for patients with chronic conditions, such as diabetes, hypertension, and heart disease.
The leaders/coaches of this team play a crucial role in ensuring its success. They provide guidance, facilitate collaboration, and establish a shared vision among team members. They promote open communication, encourage the exchange of ideas, and foster a culture of safety and quality improvement. Effective leaders/coaches prioritize patient-centered care, promote evidence-based practices, and ensure that each team member’s role and responsibilities are well-defined.
Several factors contribute to the success of this team. Firstly, their commitment to a patient-centered approach, where the focus is on delivering holistic care tailored to the specific needs of each individual patient. Secondly, their emphasis on collaboration and interdisciplinary teamwork, which allows for a comprehensive understanding of the patient’s health status and enables the development of integrated care plans. Thirdly, their utilization of continuous quality improvement strategies, such as regular team huddles, performance monitoring, and feedback loops, which facilitate ongoing reflection and refinement of the team’s processes and outcomes.
Despite their success, there are always opportunities for improvement. One area where this team can improve is enhancing their cultural competence in providing care for diverse patient populations. By actively seeking cultural awareness training and increasing their knowledge of different cultural practices, beliefs, and health disparities, the team can ensure that their care is more individualized and sensitive to the unique needs of their patients. Additionally, implementing regular peer review and case discussions can help identify areas for improvement in clinical decision-making and care coordination.
Observing this team has taught me valuable lessons that I can apply to my assigned class team. Firstly, effective communication and collaboration are critical for team success. By fostering an environment where all team members feel comfortable sharing their perspectives and ideas, we can optimize our collective knowledge and expertise. Secondly, a patient-centered approach, rooted in compassion and empathy, is essential to providing high-quality care. Lastly, continuous learning and reflection are vital for ongoing improvement. Regular evaluation of our team’s processes and outcomes can help us identify areas for growth and development.
An analysis of the wrong-site surgery event in critical concept 8.2 highlights the importance of conducting a root cause analysis (RCA) to identify and address the underlying causes of adverse events. In this case, several root causes were identified, including the clinic’s failure to review and confirm the accuracy of the surgery confirmation form, the nurse’s failure to read the patient’s history and physical examination report, and the surgeon’s distraction during the preoperative checklist.
To prevent similar events from occurring, a literature review and internet search reveal several corrective actions aimed at preventing wrong-site surgeries. These actions can be applied to the hospital described in critical concept 8.2. Some of the actions include:
1. Implementing a standardized preoperative verification process: This involves a systematic and standardized approach to verify patient identity, correct procedure, and surgical site. This process should involve multiple healthcare professionals, including the surgeon, anesthesiologist, nurses, and the patient, to ensure comprehensive verification.
2. Improving communication and documentation: Enhancing communication between healthcare professionals and ensuring accurate documentation can help prevent errors. This can be achieved through the use of standardized electronic health record systems, clear and legible documentation, and the implementation of strict protocols for verifying patient information.
3. Utilizing time-outs: Before every surgical procedure, implementing a mandatory time-out process where the entire surgical team pauses to verify essential information, including patient identity, procedure, and surgical site, can help catch any potential errors or discrepancies.
4. Implementing a culture of safety: Creating a culture of safety within the healthcare organization is crucial for preventing adverse events. This includes promoting reporting of near-misses and adverse events, conducting regular safety training and education, and emphasizing the importance of open communication and learning from errors.
5. Engaging patients as active participants: Involving patients in the surgical process and ensuring their active participation can help prevent wrong-site surgeries. This can be achieved through patient education, informed consent discussions, and encouraging patients to speak up and ask questions about their planned procedure.
In conclusion, implementing these corrective actions can significantly reduce the occurrence of wrong-site surgeries, as well as improve patient safety and overall healthcare quality. It is essential for healthcare organizations to prioritize patient safety by adopting strategies aimed at preventing adverse events and fostering a culture of continuous improvement.