You are expected to address the requirements associated with the Case Study presented below. The product associated with this case will include:
As the Risk Manager for Betsy Johnson Regional Hospital, you will be conducting a Failure Mode and Effects Analysis (FMEA) using a spreadsheet developed by the American Society for Quality (ASQ). More specifically, you’ll be conducting this qualitative analysis on the premature death of the female patient who was cared for at Betsy Johnson Regional Hospital. In addition to completing your FMEA using the ASQ spreadsheet, you will draft a “cover” business memorandum with the spreadsheet as an attachment. The memo should be written to the Vice President for Risk Management and Compliance, Ms. Dana Foster.
Keep in mind that this product (memo and FMEA attachment) is to be prepared consistent with that expected of health services managers. It should be prepared for the benefit of the external stakeholder (customer) and not the instructor. You are expected to carefully read the case before proceeding with the assignment. It is not uncommon for health services managers or administrators to perform an FMEA when developing new programs, changing existing programs, and following an avoidable incident as one approach to isolating potential causal factors and proposing improvement strategies.
Dr. John D. Banja is a professor in the Department of Rehabilitation Medicine and a medical ethicist at the Center for Ethics at Emory University in Atlanta. His area of specialization is patient safety ethics. The following is an actual case that Dr. Banja consulted on which took place in an acute care hospital that we’ll refer to as Betsy Johnson Regional Hospital. Some might argue that this type of case is why we need a robust risk management program in health care entities.
A female patient [Jane Doe] was admitted for abdominal surgery. The surgeon began the procedure laparoscopically but then switched to an open procedure, i.e., a laparotomy. The hospital’s protocol requires that when such a switch occurs, an image must be taken of the surgical site and sent to radiology for a read while the patient remains in the OR. The image was taken and sent, but was mistakenly labeled as regular instead of urgent. Because of the delay of the radiologic report, a decision was made—by who was unclear—to transport the patient to the recovery room. The radiologic report was never communicated to the surgeon. When the report finally came to light, the radiologist claimed he thought he saw a drain in the surgical site. In fact, what the radiologist saw wasn’t a drain but a laparotomy pad that had mistakenly been left inside the patient. Furthermore, the surgeon had nicked the patient’s sigmoid colon, which went unrecognized until she was readmitted some days later. Upon readmission, the patient had a high fever, tachycardia, elevated blood pressure, extreme abdominal pain and other symptoms suggesting sepsis. The surgeon’s initial order for a CT scan was somehow lost in the system and had to be re-ordered, causing a delay. The imaging was further postponed for numerous reasons that would be contested by plaintiff and defense counsels as negligent or reasonable, respectively. Approximately 15 hours after the imaging was supposed to occur but didn’t, the patient coded and experienced a 14-minute episode of hypoxia/anoxia while being resuscitated. When her abdomen was re-opened, 2,500 cubic centimeters of fecal matter had seeped into it from the sigmoid colon laceration. Some days later, the patient was discharged but in a profoundly compromised cognitive state. A few weeks later, a decision was made to discontinue life-prolonging treatment and the patient expired. The case settled out of court.
Banja, J. D. (2018). Deaths from medical errors: What to believe, what to think?
For this assignment, you’re assuming the persona of Risk Manager with Betsy Johnson Regional Medical Center.
Taking into consideration facts presented in the case involving Betsy Johnson Regional Hospital, you are being asked to perform a Failure Mode and Effects Analysis (FMEA) using the provided spreadsheet. There are links within the spreadsheet that are designed to assist you in successful completing this qualitative analysis on the premature death of the patient, Jane Doe. The Vice President of Risk Management, Ms. Dana Foster, would like to review your analysis and recommendations on how best to prevent similar instances from occurring in the future. As you prepare to conduct your FMEA, you may want to consider your answers to the following questions.
1. What is the incident being analyzed?
2. What went wrong?
3. What is the impact on the key output variables or internal requirements?
4. How severe is the effect to the customer?
5. What causes the key input to go wrong?
6. How frequently is this likely to occur?
7. What are the existing controls that either prevent the failure from occurring or detect it should it occur?
8. How easy is it to detect?
9. What are the actions for reducing the occurrence of the cause or improving the detection?
10. Who is responsible for the recommended action?
11. What is the target date for the recommended action?
Instructor tip: You should use the information provided within the case to complete as much of the FMEA as possible, and then use your imagination to fill in any gaps. It should go without saying, the portions that come from your imagination should be realistic in nature.