Quality Improvement and Patient Safety

Quality Improvement and Patient Safety
Question:

Post results of a completed fishbone diagram for a medical error (Safety Case Study Description” I will attach the CASE Study with this order). Also discuss for this case the implications for personal versus system accountability. Was there a reckless act (and why or why not)? If so, how should the system respond?

Patient Safety Case

Mrs. Jones is a 79-year-old woman who presented to an after-hours clinic with a
1-week history of diarrhea and progressive weakness. Due to signs of
dehydration, the patient was directly admitted to the hospital. Past medical
history was notable for stroke with residual left-sided hemiparesis, hypertension,
coronary artery disease with ischemic cardiomyopathy, peptic ulcer disease,
asthma, and obesity. Two weeks prior to this admission, she had spontaneously
developed right ankle and foot pain and had been evaluated in the emergency
department (ED) of another hospital. The family was told of a possible fracture
and a splint was applied. She was instructed to follow up with an orthopedist as
soon as possible. Due to transportation difficulties, the patient was not seen in
follow up.
On physical examination, she was afebrile and appeared weak. She had a leftsided
hemiparesis. The right ankle and foot were in the same splint that had
been applied 2 weeks earlier. When examined, the ankle had a normal range of
motion with no localized tenderness. A stool specimen collected in the ED was
subsequently positive for Clostridium difficile toxin. At the time of admission, a
release of information was signed and faxed to the other hospital to obtain
records of the recent ED visit for the ankle and foot injury. The family requested
an orthopedic consultation to expedite work-up. Outside records of the previous
ED visit did not arrive promptly, so another x-ray was taken of the right foot and
ankle. This x-ray was read by the radiologist as showing a right ankle trimalleolar
fracture and dislocation. The consulting orthopedist reviewed the x-ray report
then briefly examined the patient. Surgery was recommended and discussed with
the family, and consent was obtained.
The next morning, the patient was taken to the operating room (OR), and spinal
anesthesia was administered. The orthopedist was scrubbed and was preparing
to operate. The ankle x-ray was on the view box in the OR. Prior to making an
incision, the orthopedist reviewed the x-ray and was shocked to notice that it was
a left ankle x-ray showing a trimalleolar fracture. A prompt examination of both of
the patient’s ankles under anesthesia did not demonstrate any clinical evidence
of fracture or dislocation. The x-ray was clearly labeled as belonging to the
patient. Stat x-rays of both ankles were then done in the OR. The left ankle was
intact, and the right showed an intact ankle with a healing fracture of the fifth
metatarsal bone.
During the ensuing confusion, one of the OR technicians recalled that another
patient had undergone an operative reduction-internal fixation (ORIF) of a left
ankle trimalleolar fracture 2 days prior. It was later confirmed that the x-ray
showing the left ankle trimalleolar fracture was mislabeled by date and patient
and belonged to this other patient who already had surgery.
The spinal anesthesia was reversed, and the patient was returned to her room
and fortunately did not have any consequences. Full disclosure and an apology
were given to the family.
The patient continued to recover from the dehydration and colitis and was able to
be discharged from the hospital. Treatment for the metatarsal fracture consisted
of a supportive boot. By the time of discharge, a faxed copy of the ED records
from the outside hospital had been received. Included in these records was an xray
report describing a non-displaced, fifth metatarsal fracture of the right foot.
What course of action should be taken following this event to ensure the quality
and safety of future patients?