Case Analysis : ' We Meet Felix '

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In this case presentation, we meet Felix, a 68-year old man who is admitted to the hospital for monitoring, following a commonly performed surgery. His stay should have been uncomplicated and short term, but instead it turned into a complex extended hospitalization that left his wife angry, and threatening. Felix’s wife wanted Renee, Felix’s daytime nurse fired. The initial investigation by the nurse manager, and the first meeting with Felix’s wife by the nurse manager and grievance counselor was not atypical. The focus was Renee, the front line staff. It has long been the history, to find simple, surface solutions to complex problems. Blame the individual caregiver, rather than dig deep to determine the root cause. This case study uses an …show more content…

According to the Institute of Healthcare Improvement [IHI] (2016a), unsafe acts may be grouped as violations or errors. Violations are actions that intentionally depart from established standards or operating procedures. On the other hand, errors can be related to slips, lapses, or mistakes. Slips and lapses are errors of execution. An observable error, or slip, is when you push the wrong button on a medication-dispensing machine. A lapse occurs when you forget to do something, such as not remembering to administer a medication; they are not observable. Mistakes are related to wrong actions that are failures in decision making or planning; they stem from rules or knowledge. They are not intentional. Mistakes can occur when you have the knowledge but apply it incorrectly. You think your action should be x and it is y - you make a mistake. Mistakes also occur when you do not have the knowledge, such as a new nurse or doctor, and need to make a decision. A systems approach. James Reason, a psychologist who strongly influenced the study of human error asks us to consider a systems approach, rather than a person approach, when dealing with human fallibility (IHI, 2016a). His conceptual model of accident causation in large organization is called the Swiss cheese model. The slices of cheese are like layers of defense against harm. With an individual hole, seldom causing harm. However, when the holes line up, harm

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