Medical Error
In this scenario, it’s evident that the profound failure in communication and teamwork among healthcare professionals led to a severe violation of Interprofessional Education/Interprofessional Practice (IPE/IPP) competencies. This incident, where a hysterectomy was performed instead of the intended tonsillectomy, underscores a significant lapse in the core competencies of interprofessional practice.
One major breakdown in this scenario is the need for adherence to the preoperative verification process, which is critical for patient safety. Recent literature stresses the importance of comprehensive preoperative protocols and checklists in ensuring the correct surgical procedures are performed (Fudickar, Hörle, Wiltfang, & Bein, 2019).
Moreover, the Joint Commission (2019) highlights the critical role of effective communication in healthcare, particularly in preventing severe surgical mishaps like wrong site, wrong procedure, and wrong-patient surgeries. This incident emphasizes the need for stringent adherence to safety guidelines to avoid such dire errors and ensure the delivery of safe and effective healthcare delivery.
The significant breakdown here relates to the core competencies of Interprofessional Education/Interprofessional Practice, especially in communication and teamwork. This lapse not only compromised patient safety but highlighted the systemic need for continuous quality improvement and adherence to best practices in healthcare.
References:
Fudickar, A., Hörle, K., Wiltfang, J., & Bein, B. (2019). The effect of the WHO Surgical Safety Checklist on complication rate and communication. Deutsches Ärzteblatt International, 116(40), 679–686. https://doi.org/10.3238/arztebl.2019.0679
The Joint Commission. (2019). Quick Safety Issue 50: Developing resilience to combat nurse burnout. Retrieved from https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-50-developing-resilience-to-combat-nurse-burnout/
What we need is:
will use one of the change theories and develop a plan to improve the identified problem.
Please see the pic attached to know what is the scenario about.
The change theories are:
1- Lewin’s Force Field Theory.
2- Havelock’s Theory.
3- Kotter’s Change Model.
4- Juran’s Trilogy Model.
