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? 

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? 

 

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.

Expert Solution Preview

Introduction:
In this assignment, we will be exploring two different topics related to healthcare teams and patient safety. In Part 1, we will discuss the importance of teamwork in healthcare and analyze a specific team’s mission, its leadership, and factors contributing to its success and areas for improvement. In Part 2, we will delve into the incident of wrong-site surgery and conduct a literature review to identify corrective actions that can help prevent similar events from occurring in the future.

Part 1:
The team of interest for this assignment is the Quality Improvement Team (QIT) at a local hospital. The mission of this team is to continuously improve the quality of patient care and safety within the hospital. The QIT consists of a multidisciplinary group of stakeholders, including physicians, nurses, healthcare administrators, and quality assurance specialists. The leaders or coaches of the QIT are usually experienced healthcare professionals who possess strong leadership skills, knowledge of quality improvement methodologies, and the ability to facilitate teamwork and collaboration.

One of the key factors that contribute to the success of the QIT is effective communication and collaboration among team members. The team members come from different backgrounds and have diverse expertise, which allows for a comprehensive and holistic approach to problem-solving. By ensuring that all relevant perspectives are considered, the team is able to develop innovative and effective solutions to improve patient care.

However, there are also opportunities for the QIT to further improve. One area of improvement is the utilization of data and evidence to drive decision-making. While the team recognizes the importance of data, there is room for improvement in terms of utilizing data analytics and research to inform their improvement efforts. Incorporating more robust data analysis techniques and evidence-based practices can help the team make more informed decisions and achieve better outcomes.

From observing the QIT, I have learned several valuable lessons that can be applied to our assigned class team. Firstly, fostering a culture of trust and mutual respect is crucial for effective teamwork. This can be achieved through open and transparent communication, active listening, and valuing each team member’s contribution. Secondly, providing opportunities for continuous learning and professional development is essential for team members to enhance their skills and knowledge in quality improvement. Lastly, maintaining a patient-centered approach and incorporating patient feedback into the team’s improvement efforts can lead to more meaningful and impactful changes in healthcare delivery.

Part 2:
Wrong-site surgery is a serious adverse event that can have severe consequences for patients and healthcare providers. Conducting a literature review and internet search reveals several corrective actions aimed at preventing wrong-site surgeries. Some of these actions would help prevent a similar event from occurring at the hospital described in critical concept 8.2.

One such corrective action is the implementation of a standardized pre-procedure verification process. This process involves verifying patient identity, procedure, and site with multiple healthcare providers involved in the surgical process. This verification should occur both verbally and visually, with all team members confirming the accuracy of the planned procedure and surgical site. By incorporating this standardized verification process into the hospital’s surgical workflow, the likelihood of wrong-site surgeries can be significantly reduced.

Another corrective action is the use of surgical site marking protocols. This involves marking the intended surgical site with a non-removable, indelible mark, such as surgical ink, before the patient enters the operating room. The marking should be performed by the surgeon or a designated healthcare professional following established guidelines. This visual cue serves as an additional layer of safety, providing a clear indication to all team members of the intended surgical site.

Additionally, preoperative briefing and time-outs are effective strategies to prevent wrong-site surgeries. Before starting the procedure, the entire surgical team should gather for a preoperative briefing, where they review critical patient information, confirm the procedure, and discuss any potential concerns or risks. A time-out should also be conducted immediately before incision, during which the team pauses to confirm the patient’s identity, procedure, and surgical site.

By implementing these corrective actions, the hospital can establish a safer environment and reduce the occurrence of wrong-site surgeries. However, it is important to note that each healthcare setting is unique, and a comprehensive approach is necessary to address all contributing factors and ensure patient safety. Regular training, education, and ongoing monitoring of compliance with safety protocols are essential to maintain the effectiveness of these corrective actions.