surgeon drilled into the wrong side of a patient’s head in a procedure to drain blood, management homework help

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Each of the following operating-room mishaps occurred in hospitals in the state of Rhode Island:

  • A surgeon drilled into the wrong side of a patient’s head in a procedure to drain blood.

  • A surgeon operated on the wrong knee of a patient undergoing arthroscopic surgery.

  • A surgeon operated on the wrong side of a child’s mouth during surgery to correct a cleft palate.

  • A surgeon anesthetized the wrong eye of a patient about to undergo eye surgery.

  • A surgeon operated on the wrong finger of a patient during hand surgery.

One
of the latest instances of so-called wrong-site surgery—an operation
conducted on a body part other than the one intended by patient and
surgeon—took place at Rhode Island Hospital, the state’s largest and the
main teaching hospital of prestigious Brown University. According to
the chief quality officer of the hospital’s parent company, Lifespan,
the incident served to underscore how difficult it is to prevent such
errors. The hospital, said Mary Reich Cooper, is committed to safety,
and “every time one of these kinds of things happens, that commitment is
just made stronger.”

There’s
apparently some question, however, about how many times such errors
have to happen before a hospital’s commitment is strong enough. Only two
years earlier, the state department of health had fined Rhode Island
Hospital $50,000 for the occurrence of three wrong-site surgical errors
in a one-year span—all of them involving procedures in which doctors
drilled into the wrong side of a patient’s head. “Frustrating—in capital
letters—is probably the best way to describe the mood here,” said
department director David R. Gifford after the wrong-finger incident.
Asked if there might be some fundamental flaw in the hospital’s
procedural system, Gifford replied, “I’m wondering that myself.”

All
the incidents of wrong-site surgery on our list occurred in one state
during a period of just over two years, and the Joint Commission on
Accreditation of Healthcare Organizations, which evaluates more than
15,000 health-care facilities and programs in the United States,
estimates that wrong-site surgery occurs about 40 times a week around
the country. A study in Pennsylvania conducted by the state’s Patient
Safety Authority added “near misses” into the mix and found that an
“adverse event” (in other words, wrong-site surgery) or a “near miss”
occurred every other day at Pennsylvania health-care facilities. “To be
frank,” says Dr. Stan Mullens, vice president of the Authority’s board
of directors, “wrong-site surgeries in Pennsylvania should never occur.”
But he hastens to add, “We’re not alone. Wrong-site surgeries are no
more common in Pennsylvania than they are in other states.”

The
Joint Commission has spent 15 years looking for ways to reduce the
number of wrong-site surgical errors, but the results so far haven’t
been very promising; in fact, the rate of occurrence is the same as it
was 15 years ago. So, what’s the underlying problem? According to the
Commission, it is communications breakdown, and some studies show that
communications failure is a factor in two-thirds of all surgical mishaps
resulting in serious patient harm or death. Surgery, of course, is
performed by teams, and the typical surgical team has at least
three core members: the surgeon, who performs the operation and leads
the team; the anesthesiologist, whose responsibility is pain management
and patient safety; and the operating nurse, who provides comprehensive
care, assistance, and pain management at every stage of the operation.
Perhaps the most logical question to start with, therefore, is: What are
the barriers to communication among the core members of a surgical
team?

According to some
researchers, the most serious barrier results from team members’
different perceptions about the nature and quality of the group’s
teamwork and communications. According to a study commissioned by the
Department of Veterans Affairs, the “most common pattern” of differing
perceptions reflects a disparity between the perceptions of nurses and
anesthesiologists on the one hand and those of surgeons on the other. In
particular, surgeons tend to believe that both teamwork and
communications are more effective than nurses and anesthesiologists do.
One item on the research questionnaire, for example, asked team members
to respond to the statement “I am comfortable intervening in a procedure
if I have concerns about what is occurring.” While surgeons reported
that the operating room (OR) environment did indeed support
intervention, nurses and anesthesiologists generally did not. Surgeons
were also more likely to report that “morale on our team is high.” In
assessing such results as these, the authors of the study wonder, “If
surgical team members have disparate perceptions about how well they are
communicating or collaborating with each other, how is it possible for
them to be collaborating optimally with other members of the surgical
team for the care of their patients?”

When
the results of a study at Johns Hopkins revealed a similar breakdown in
perceptions, the lead researcher, who is also a surgeon, admitted that
“the study is somewhat humbling to me …. We need to balance out the
captain-of-the-ship doctrine,” suggested Dr. Martin A. Makary. Makary
believes that a standardized OR briefing program is one way to improve
surgical-team communication and has helped to make
brief two-minute “team meetings” a regular step in surgical procedure
at Johns Hopkins and other university hospitals. During the meeting,
which is conducted just after anesthesia is administered, all members of
the OR team state their names and roles and the surgeon verifies the
critical aspects of the procedure, including the correct site.

Where
the policy has been adopted, according to Makary, researchers have
observed an increase in “the awareness of OR personnel with regard to
the site and procedure and their perceptions of operating room safety.”
Without such a policy, Makary points out, many surgeons simply walk into
the OR and start operating without even asking the names of the other
medical personnel in the room. Such measures as team meetings hold some
promise in the effort to reduce surgical error, as do checklists and
time-outs, both of which require periodic confirmation of the critical
components of a procedure. But “the unfortunate truth,” cautions Dr.
Mark R. Chassin, president of the Joint Commission, “is that no hospital
today … can guarantee that [surgical errors] will never happen. We do
not know how to perfect our processes….” In some hospitals, he admits,
the Commission has even encountered “denial or serious avoidance of the
potential for real problems,” and he recommends that patients everywhere
ask surgeons in advance what steps will be taken to prevent errors
while they’re in the OR.

Case Question

  1. Explain a surgical team in terms of its role structures. What factors might lead to role ambiguity? To role conflict? To role overload

  2. Read the above case and give direct responses to the question , (i.e. no introduction and conclusion paragraphs required). Do NOT copy and paste from the chapter readings or other articles. If you refer to any articles, you need to rewrite the major points from them in your own words and give proper citation. This paper requires at least 400 words.

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