Recognizing Medical Complications : Medical Errors

In the case listed here Dr. Loren J. Borud was scheduled to perform surgery on Mr. Michael Hicks early on a Friday morning. The surgery was liposuction and a scar repair procedure. Dr. Loren informed the patient the procedure would take approximately ninety minutes, but

Blackman’s complaints, signs, and symptoms were downplayed and eventually he was transferred out of the PACU with no further plan of care, assessment of the issues, or action to alleviate his complaints. 3 days postoperative, with continued scheduled Ketorolac administration, Lewis’ pain was unfathomable. Despite repeated attempts to gain the attention of the healthcare team to Blackman’s impending crisis, his pain was once again downplayed. The nurses again failed to recognize the significance of his increasing abdominal pain and deterioration, chalking it up to gas pain, suggesting only movement and a bath as the acceptable plan of care. Lewis’ symptoms continued to progress and he deteriorated to a state of clinical shock evidenced by abnormally low temperature and increased heart rate and respiratory rate accompanied by extreme paleness, enlarged abdomen, with absent bowel sounds. Inexperience, lack of recognition, and failure to rescue eventually led to the unexpected death of Lewis Blackman (Acquaviva, et al., 2013).

Imagine waking up from kidney surgery only to realize that there are stitches not only on your stomach, but also on your chest. Imagine the doctor coming up and having to explain to you that his surgical tech got a weak stomach and with scalpel in-hand, fell and put a puncture wound large enough for stitches on your chest. You would be shocked at the severe lack of professionalism by the surgical technologist, and you would question the hospitals inequity.

It is shocking to know that every year 98000 patients die from medical errors that can be prevented(Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.), 2000). Medical errors are not a new issue in our healthcare system; these have been around for a long time. Hospitals have been trying to improve quality care and patients safety by implementing different strategies to prevent and reduce medical errors for past thirty years. Medical errors are the third leading cause of death after heart disease and cancer in America (Allen, 2013). In addition medical errors are costing our healthcare system an estimated $735 billion to $980 billion (Andel, Davidow, Hollander, & Moreno, 2012).

This documentary video is very informative and very useful as eye-opener to all that works in the healthcare industry. John Hopkins patient safety expert have calculated that more than 250,000 deaths per year are due to medical error in the U.S. This large number, victims of medical error, leads to a stigma that people became questioning and doubting the capabilities of healthcare providers resulting on losing trust. This video “Chasing Zero” is a reminder that all nurses, doctors and all the people that works in healthcare industries should be very cautious on the care they provide to patients. A single error can hurt and worst, it can kill someone. This video made me realize as a nurse, that anyone can make a big mistake regardless of years

The medicinal experts on staff for the 12 hours that the patient was in painful distress while she was being drowned by the feeding solution, neglected to perceive that she was in trouble until it was past the point of no return. While this is obviously a blatant case of medicinal negligence, not all medical malpractice cases are quite so obvious, and not every single medical procedure with a troublesome result can be viewed as medical malpractice negligence. The essential prerequisite for medical malpractice is that the doctor or other medical expert has breached the acknowledged standard of care for their specialty in their geographic area, and that the breach caused harm to the patient. Doctors, as human beings, commit errors consistently, yet in the event that their mistake does not bring about injury or harm to the patient, there are no grounds for lawful

The healthcare team honored the patients’ wishes as best as possible; the only time we bothered the patient was when we changed the dressings on the pressure ulcers located on the anterior portion of the left foot and right buttocks and when we provided the patient with PRN pain medications. Since this is a Medical Surgical floor, we were required to do one assessment, and that occurred during the time the health care team went in as a group to clump all of the care up and do it at one time. The only negative experience that had occurred was when the patient was expressing non-verbal signs of pain – and from that point, we worked quickly to give him his PRN pain medications to manage it.

The “Lewis Blackman Story” told by Helen Haskell, a person who continues to advocate for change and improved quality of care. Lewis Blackman the son of Helen Haskell died at age fifteen after developing complications after surgery that included incorrect administration of a medication and a nursing team who failed to see the changes in patient’s condition and effectively and sufficiently respond to the change in a timely manner ultimately resulting in failure to rescue and the patient’s death. More specifically, the staff failed to recognize the signs of shock that this patient. Likewise, no rescue plan was in place. Lastly, failed protocols and failed leadership

Cognitive errors of omission and commission are the most common types of medical errors that will happen in the workplace environment.

On 6/11/15 at 2:00 pm, I called Dr. McClain at his listed home number to confirm he was still in the area and to inquire if he would be available for an interview at some point. Dr. McClain began explaining that to his knowledge all of the complaints had been “kicked out” except for one case involving an ileostomy reversal. That complaint resulted from him being told not to have contact with patients since he was under investigation. The patient was upset because they could no longer see him, McClain stated.

That being stated, if a patient must be placed on restraints, qualified professionals must have a comprehensive understanding of patient outcomes that correspond with the use of restraints. First and foremost, skin integrity is placed at risk if proper placement and management of patient care while in restraints is not implemented as with the case of Mr. J. There is numerous evidence based research studies conducted that correlate the use of restrains with an increase in pressure ulcers (Baumgarten, Margolis, Localio, Kagan, Lowe, Kinosian, Abbuhi & Abbuhi, 2010).

Students go through four years of medical schools and countless years of residency just to learn and practice medicine and its connection with humanities. Once they are done with rigorous training, they believe that they, themselves, know everything and that every patient will leave the hospital or clinic cured, treated, and happy. However, that is not the case. No matter how one does on their med school boards, physicians are prone to mistakes. Physicians have encountered at least one mistake during their career. Different people have different perspectives concerning errors in the medicine field. Atul Gawande’s “Complications: A Surgeon’s Note on an Imperfect Science” and Dr. Goldman’s TED Talk emphasize errors in a hospital or clinical setting.

Medical errors are avoidable mistakes in the health care. These errors can take place in any type of health care institution. Medical errors can happen during medical tests and diagnosis, administration of medications, during surgery, and even lab reports, such as the mixing of two patients’ blood samples. These errors are usually caused by the lack of communication between doctors, nurses and other staff. A medical error could cause a severe consequence to the patient in cases consisting of severe injuries or cause/effect any health conditions, and even death. According to recent studies medical errors are not the third leading cause of death in the United States. (Walerius. 2016)

Errors pervade in our lives whether it is our home, in our workplace, or in our society. The effects of healthcare errors have impacted all our lives either directly or indirectly. Patient safety and quality care are at the core of healthcare system which strongly depends upon nurses. “To achieve goals in patient safety and quality, thereby improve healthcare, nurses must assume the leadership role. Nurses need to ensure that they and other healthcare providers center healthcare on patients and their families. Even though the quality and safety of healthcare is heavily influenced by the complex nature

Medication error is one of the biggest problems in the healthcare field. Patients are dying due to wrong drug or dosage. Medication error is any preventable incident that leads to inappropriate medication use or harms the patient while the medication is in the control of the health care professional,or patient (U.S. Food and Drug Administration, 2015). It is estimated about 44,000 inpatients die each year in the United States due to medication errors which were indeed preventable (Mahmood, Chaudhury, Gaumont & Rust, 2012). There are many factors that contribute to medication error. However, the most common that factors are human factors, right patient information, miscommunication of abbreviations, wrong dosage. Healthcare providers do not intend to make medication errors, but they happen anyways. Therefore, nursing should play a tremendous role to reduce medication error