Order Description
Question:

Post a reaction to a fellow student. Critique their fishbone diagram using one of the structures discussed in this week’s lecture. Do you agree with your colleague’s conclusions about personal versus system accountability? Would the system response they propose work within your organization, and why or why not? No citations required.?

the fellow student post as the following

“Case Analysis:

Mrs. Jones showed up to the clinic after working hours and admitted as a medical problem. She is known for multiple medical health conditions including recent Rt. Foot and ankle pain due to non-displaced fracture of the 5th metatarsal bone treated with splint in another hospital upon which medical report was demanded.

The patient on admission was treated for her current problem of dehydration and colitis, inspite of current treatment, the patient’s family demanded an orthopedic consultation and the conclusion of serious adverse effect of conducting unnecessarily surgery could have happened.

The sequences of adverse events:

1- The patient was not properly evaluated by treating team since the patient is demanding the referral to orthopedics rather this process could have been initiated by the staff on charge of the patient.

2- The case was not evaluated and seriously examined by the orthopedic surgery team either the patient was examined by an intern, resident or by orthopedics staff who is so ignorant.

3- The patient was sent to the OR for fixation of Rt. trimalleolar dislocated fracture based on the radiologist’s report without reviewing the images prior to sending patient to surgery.

4- The patient was exposed to epidural anesthesia and she is known of complex cardiac problems which carries a significant risk.

5- In the OR prior to making an incision was performed, the X-ray fortunately was reviewed which was mislabeled Rt. for Lt though it was holding the same patient’s name. (Stat x-rays of both ankles done and both ankles were intact).

6- Delayed arrival of the medical report from the primary institution.

Many issues are involved in this case:

The healthcare system:

A) The patient could have instant availability of the medical report regarding the recent rt. ankle pain and what was the condition and the management received. This problem could have been addressed by establishing more national unified electronic medical healthcare records which always are available in all medical facilities.

B) Within the institution the patient need to be examined by competent staff and document all the finding in a special documentation format (or in electronic medical records with safety measure and no major decision will be conducted unless these measures are fulfilled).

C) Appropriate orientation for all new staff and they should be able to understand and apply all the policy and procedures to all medical staff.