Based on the Final Project scenario and the National Patient Safety Goals, submit a draft of your analysis of the regulation(s) that address the safety issue you chose in the given scenario. Your analysis should include the identification of healthcare regulations or accreditation standards related to the safety issue and the analysis of their impact on the given organization.
Scenario
The event began with the admission of two patients with similar names; the names Joan Smith and Jane Smyth are used. Smith was a direct admission to the telemetry unit, and Smyth was a transfer. Smith was subsequently transferred from telemetry to oncology.
On the day of the procedure, electrophysiology telephones telemetry seeking Smith, but an unidentified telemetry staff member incorrectly reports that she has been transferred to oncology, mistaking Smith for Smyth. Electrophysiology telephones oncology seeking Smith, and Smith’s nurse agrees to transport her to electrophysiology for the procedure despite the lack of a written order. Smith states that she does not want to undergo the procedure.
Smith and her chart are delivered to electrophysiology. Given the patient’s reluctance to undergo the procedure, the attending physician is called, and, despite having met Jane Smyth, the scheduled patient, the prior evening, the attending physician does not recognize that Smith is not Smyth. The attending physician instructs the nurse to prepare Smith for surgery and states that she has agreed to surgery. An electrophysiology nurse notices the consent form is missing, although the daily schedule reports that it has been obtained, and she notifies the fellow scheduled to do the procedure. The fellow notes a lack of pertinent information in the patient chart but proceeds to discuss the procedure with Smith and obtains her consent.
Approximately 45 minutes after Smith was transported to electrophysiology, an oncology resident discovers she is not in her bed and has been transported for a procedure. The resident goes to electrophysiology to determine why she has been transported there. Informed that she had been previously scheduled for the procedure, the resident assumes the attending physician has simply failed to inform him, and he leaves the unit satisfied. Approximately one hour and 15 minutes after transport, the procedure begins on Smith. Forty minutes later, a second nurse calls from telemetry to inquire why Smyth, the scheduled patient, has not been called to electrophysiology. At approximately the same time, the charge nurse in electrophysiology notices that Smith’s name does not match any name on the daily schedule. Neither discovery results in recognition of the misidentification. The telemetry nurse is told to send Smyth to the unit, and the charge nurse’s discovery is related to and dismissed by the fellow, who was at a demanding part of the procedure.
Approximately one hour after beginning the procedure, an interventional radiology attending physician goes to check Smith and is told she has been transported to electrophysiology. He follows up with electrophysiology, where the attending physician maintains that Smith is in fact Smyth. At this point, the charge nurse informs him that Smith is on the table, and a review of the patient chart bears this out. The procedure is stopped, and the patient is returned to oncology. The attending physician subsequently explains the error to the patient and her family.
Case Scenario Issue
After reading the scenario, you will choose a specific issue that is identified as a patient safety concern. You will target your analysis based on the issue you choose.
Specifically, the following critical elements must be addressed:
I. Analysis of Regulations: In this section, you will analyze the regulation and accreditation standards that impact the given scenario. Be sure to do the
following:
A. Identify appropriate healthcare regulations or accreditation standards that would apply to the department or institutional system from the given scenario.
B. Analyze the impact your identified healthcare regulations or accreditation standards could have on the daily operation and clinical practice of the department or system.
C. Explain the influence of key laws on the development of healthcare regulations or accreditation standards you have researched or reviewed. Key laws could include but not be limited to Health Insurance Portability and Accountability Act (HIPAA), Emergency Medical Treatment and Labor Act, Patient Protection and Affordable Care Act, and others. Be sure to provide examples to support your response.
D. Determine key similarities and differences between federal and state healthcare regulations or accrediting standards that would apply to the department or system. For example, how might HIPAA be similar to an applicable state regulation? How might it be different?
E. Analyze federal and state healthcare regulations or accrediting standards for how they inform deemed status of healthcare organizations. In other words, what regulations and standards must be met?
F. Explain the implications of deemed status as it relates to healthcare regulations or accreditation standards that would apply to the institution or system. In other words, what is the importance of deemed status? How would it apply to and affect your department or system (or the institution)?
Rubric
Guidelines for Submission: This milestone should adhere to the following formatting requirements: 3 to 4 pages, double-spaced, all references cited in APA
format.
