HAP 417

Part 1 (10 pts):

Teams play a major role regardless of the setting. In health care, teams are formed to focus on issues that are in need of improvement, they need to have input from a variety of stakeholders. For this assignment, select a team that is of interest to you - describe the team and their mission - what is the role of the leaders/coaches, in your opinion, what makes this team successful? Are there any opportunities for this team to improve -what are they? What are some of the key lessons learned from observing this team and how you will be able to apply them to your assigned class team? (500-750 words).

Part 2 (20 pts):

RCA (Root Cause Analysis) is an accident investigation technique undertaken to find and fix the fundamental causes of an adverse event. It is similar to any improvement method that follows the steps of the Plan-Do-Study-Act cycle.

Read the description of the wrong-site surgery event in critical concept 8.2 and the root causes identified by the team who conducted the RCA (below). Conduct a literature review and Internet search for corrective actions aimed at preventing wrong-site surgeries. Which of these actions would help prevent a similar event from occurring at the hospital described in critical concept 8.2? (At least 3 paragraphs, be sure to include your references in proper APA format).

Critical Concept 8.2

A 62-year-old man was scheduled to undergo an arthroscopy procedure. Three weeks before the surgery, the orthopedic clinic telephoned the hospital to sched- ule the man's procedure. At that time, the front-office staff in the clinic mistak- enly scheduled a left-knee arthroscopy instead of a right-knee arthroscopy. The surgery scheduling clerk at the hospital faxed a surgery confirmation form to the clinic. Per hospital policy, the clinic is expected to review the information on the form, verify the accuracy, and fax the signed confirmation back to the hospital. The clinic staff were busy and did not fax the confirmation back. On the day of the surgery, the patient's paperwork indicated that the surgery was to be performed on his left knee, per the original phone call from the clinic. The surgery schedule, a document used to plan the day's activities in the oper- ating area, also indicated that the patient was to have a left-knee arthroscopy. The man was taken to the preoperative holding area, where a nurse spoke with him about his upcoming procedure. Relying only on the surgery schedule, the nurse asked the patient to confirm that he was having an arthroscopy on his left knee. The man told the nurse that he had been experiencing pain in both knees and that he'd eventually need procedures on both of them. He thought he was scheduled for surgery on his right knee that day but figured that perhaps the doctor had decided to operate on his left knee instead. The nurse did not read the history and physical examination report that the patient's doctor had brought to the hospital that morning. If she had read this report, she would have noticed that it indicated the patient was to have surgery on his right knee that day. The anesthesiologist examined the patient in the preoperative holding area.

When asked about the procedure, the man was confused about which knee was to be operated on that day. The anesthesiologist wrote knee arthroscopy in his notes in the patient's record. The patient was taken into the operating room, where the surgeon was waiting. The surgeon spoke with the patient about the upcoming procedure on his right knee, and the patient signed a consent form indicating that surgery was to be performed on the right knee that day. The sur- geon marked his initials on the man's right knee in ink to designate the surgery site. The anesthesiologist and scrub nurse readied the room for the procedure. The patient was anesthetized and fell asleep. Thinking the man was having surgery on his left knee, the nurse placed a drape over his right knee, not notic- ing the surgeon's initials. The left knee was placed in the stirrup and prepped for the procedure. The nurse then asked everyone in the room to confirm that the man was the correct patient and that he was having an arthroscopy on his left knee. Everyone in the room said yes except the surgeon, who was busy pre- paring for the procedure. Distracted, he nodded his head in agreement. The nurse documented on the preoperative checklist that the patient's identity, procedure, and surgery site had been verified. The surgeon performed the arthroscopy on the knee that had been prepped the left one. When the patient awoke in the surgical recovery area, he asked the nurse why he felt pain in his left knee and told her the procedure should have been performed on his right knee. The nurse notified the surgeon, who immedi- ately informed the patient and his family about the mistake.