Adverse Event Analysis

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The goal of patient safety is to prevent harm to patients Mitchell (n.d.). Patient safety in any health system is critical not only for the credibility of the system, but for patient trust and satisfaction as well. Adverse outcomes are defined as any injury or harm resulting from medical care (Watcher, 2008). Adverse outcomes can result in death and disability and cost the health system dearly. Bernard and Encinosa (2004) reported that in the U.S. it costs twice as much to care for patients that experienced adverse outcomes. The Institute of Medicine (IOM) (2000) reported that adverse outcomes cost the U.S. more than 16 billion dollars or 6% of total inpatient costs. Therefore, adverse events are costly both in terms of human life and fiscal resources. In Dept Analysis of What Went Wrong / Issues that Impact Health Care Quality In reviewing this case study, it is the writer’s opinion that poor communication between doctors treating this patient, limited patient assessment, provider bias/judgment, and inferior diagnostic procedures contributed to this adverse event. Poor Communication Ongoing, clear, open, and transparent communication between physicians seeing the same patient is critical since this can reduce medical errors, improve quality of care, and increase patient safety (Institute of Medicine, 2000). In this case study, no type of formal or informal communication between this patients’ PCP, internist, and the neurologist was reported. Assessment In reviewing the medical care provided ,it seems that the patient’s previous medical history clouded her doctor’s decisions. Because of this, none of her doctors opted to dig deeper into other possible reasons for her daily headaches. Many factors that should have been... ... middle of paper ... ...5-6773.2006.00504.x Jerant, A. F., & Hill, D. B. (2000). Does the use of electronic medical records improve surrogate patient outcomes in outpatient settings? The Journal of Family Practice. 49 (4), 349-357. Kamaka, M.L. (2010). Designing a cultural competency curriculum: Asking the stakeholders. Hawaii Medical Journal. 69 (3), 31-34. Institute of Medicine (2000). To Err is Human: Building a safer health care system. Kohn L., Corrigan, J., Donaldson, M., eds. National Academy Press. Mitchell, P. H. (n.d). Defining patient safety and quality care. Retrieved from http://www.ahrq.gov/qual/nurseshdbk/docs/MitchellP_DPSQ.pdf Strauss, S.E., Richardson, W.S, Glasziou,P., & Haynes, R.B. (2005). Evidence-based medicine: How to practice and teach EBM. (4th ed). New York: Elsevier. Watcher, R. M. (2008). Understanding patient safety. New York; McGraw Hill

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