A Case Study Analysis Of A Radiological Reporting Error In Healthcare

Incident Description

1. Discuss what kind of incident occurred.

2. What defenses in the system failed in this case?  Can you construct a Swiss cheese analysis of the system defenses and what occurred? 

3. What was the culture like in this care setting(s)?  What was the leadership like? How do you know?

4. Analyze issues pertaining to human factors, teamwork and communication that arise in this case? Speaking up?  Vulnerability around handoffs?

5. To what extent do other concepts like apology, learning, violations, patient engagement & empowerment fit into this case?  

6. Is use of any patient safety tools evident? Which ones, could others be used?  

7. Do you see evidence of biases in decision making contributing to the error in this case?

8. Does anything else need to be done by those involved in the case?  If so, briefly outline what needs to happen and discuss issues or challenges people should be aware of as they try to implement changes.  

9. Discuss the extent to which there are systems problems versus accountability problems in this particular case.

10. Discuss any other aspects of the case in the context of course concepts not included in the above questions.

In the provided case study, incorrect reporting of the radiological test for Mr. M was mentioned who was a stroke patient and was suffering from significant speech and mobility disability. Mr. M observed a swelling in his right ankle and after primary diagnosis, doctors asked him to undergo ultrasound test of his right leg so that the presence of blood clot that has the ability to stop his breathing by reaching out his lungs can be identified. However, the radiologist technicians forgot to generate the correct report of his right leg and despite of the presence of a big blood clot, reports were normal. Further, as the Mr. M conversed with the radiologist during the ultrasound he informed the doctor that radiologist informed him about a big clot, physicians cross checked the report and found that Mr. M was correct and then provided him with blood thinner to prevent the clot to travel to his lungs. This incident occurred within the radiological department of the hospital was the incident of lack of attention and incident of negligence.

In this case, there are more than one faults and mistakes and the defense system was completely failed to detect the mistake at correct point. Firstly, the radiologist, who is determined to prepare the radiological report, did not generated the report of Mr. M and printed the normal template as the final report to send to the doctor. Secondly, they made the wife of Mr. M accompany in the radiological room that might diverted their concentration form the work and they communicated with each other.  If a Swiss cheese model is prepared for this incident, then the primary reason for the incident will be understood. The Swiss cheese model is based upon a layered security process that involves computer security and in depth defense system that helps to conduct risk analysis and risk management (Underwood & Waterson, 2014). Just like the form of Swiss cheese, the layers of the defense are made up of different threats and a common way need to be find out so that all the risks in the process can be managed. The Swiss cheese model is composed of three sections, active and latent failures, failure domains and holes and slices. The failure domains related to the case study was supervision of the radiologists while conducting radiological test, inclusion of staffs who are unaware of the correct format of generation of radiological report. Slices represents the barriers present in achieving quality, whereas, holes represents the weakness present in the individuals present within the system (Underwood & Waterson, 2014). The incident occurred was inclusive of active and latent failures. The active failure was not printing the original report on the normal template, and latent failure was presence of divergent within the room that affected their work efficacy.

System Defenses and Swiss Cheese Analysis

The radiological department made this silly mistake, despite of the presence of experienced radiologists in their team. Hence, through this incident the work environment of the healthcare facility can be understood. The healthcare facility did not had any defense system, which could assess the reporting system’s faults and mistakes and provide them with examples of practices to help them to prevent those faults in future. Secondly, there is a possibility that the radiologists, who performed the radiological tests were working in longer shifts and hence were completely exhausted that lead them to make the mistake. Therefore, it can be stated that the leadership and the management system lacked the sense of responsibility towards the employees as well as patients. Furthermore, the work culture was full of flaws and negligence.

In this presented case study, Mr. M was suffering from impaired communication and his wife accompanied him in the radiological department, where they heard the radiologist to whisper that Mr. M has a blood clot in his right ankle. However, the doctor communicated that the reports are normal that indicated towards the fault in the process. As the previous answer discussed, the work culture included negligence and lack of responsibility and therefore, team work, communication and handoff were affected (Wahr et al., 2013). The radiologist who saw the clot was failed to communicate the actual report to the radiologist who took the print out of the radiological report and therefore, the doctor communicated that Mr. M did not had any blood clot. The doctor could also rechecked the report as the swelling in the right ankle of the patient persisted, however, he did not rechecked the process and hence, all these incident occurred.

This incident present in the assignment, was regarding the negligence and lack of the sense of responsibility within the healthcare workers. The radiologists were unable to perform to their efficiency and generate correct report and their fault could have been deleterious to the health of the patient. Therefore the concepts of apology, learning, violation, patient engagement and patient empowerment applied to the process (Berger et al., 2012). The healthcare facility should provide a written and concise apology to the healthcare facility as it is the responsibility of the healthcare facility and involved healthcare professionals to provide the patient with written acknowledgement of the incident however in the case study, it was not provided as the patient and his wife did not demanded it. Further, regarding learning and violation, the healthcare facility should learn from the incident and violating the guidelines should become punishable so that professionals can seriously recheck all the report prior to provide them to the doctor for application of medication and intervention (Bellows et al., 2015). Finally, the concept of patient safety and patient empowerment should be implemented in the process and they should be informed about their health status, as in the case study, the patient himself was able to detect the fault in the reporting process and due to his efforts doctors were able to find out the actual report indicating big blood clot in his right ankle.

Culture and Leadership in Healthcare

Patient safety tools are equipment and practical steps and actions that helps to develop an improved and comprehensive program for quality healthcare and security. In the given case study, it was the fault of the healthcare professionals that were unaware about the mistake in their reporting system and due to the involvement of patient and his family in the system, the reporting error was identified. Hence, involvement of patient’s family in the reporting process should be included in the system as patient safety tool so that patient empowerment and improvement plan can form an amalgam of safe and quality healthcare process (Aiken et al., 2016).

Biasness in decision making is the process that is also known as cognitive bias occurs due to the lack of concentration and thinking ability and people affected with it has the tendency to take an illogical decision subconsciously (Lee et al., 2013). There are several types of cognitive bias in decision making, in which confirmation bias is the typical form of biasness that can be observed. In the given case study, the radiologist detected a blood clot in the ultrasonography, however, as per his confirmatory bias, he printed the normal template of the radiography as the report for Mr. M that could have been deleterious to his health and caused death too (Ogdie et al., 2012). This decision making process (due to subconscious negligence or due to excess work pressure) lead to create a faulty report for Mr. M.

According to Bratianu (2016), static process in any organization is the reason for faults and mistakes, hence, change or improvement is the ultimate way to prevent such incidents to occur. Therefore, in the case study, the healthcare facility and the people involved in the process should also take part in the change process. The doctor, who witnessed the fault in the radiological departments’ mistake as well as the wife of the patient take initiative so that the life of the patients could have been saved without any fatal risk factor. It is their accountability to report this incidence to the higher authority so that they can implement a scrutiny process in the system that can help to prevent such mistakes to occur in near future.

In this given incident both system and accountability related problems were identified. The system did not included any process of checking and scrutinizing the report generated by the pathological and radiological department. Further, the system did not provided proper information regarding the patient’s health status while conducting radiological or any pathological tests. Therefore, the system did not followed patient incorporation, patient safety and empowerment policies (Caravon et al., 2014). On the other hand, the professionals had accountability problems and were unable to communicate the reports within the system so that chances of fault can be minimized (Greig, Entwistle & Beech, 2012).

Human Factors, Teamwork, and Communication

In this entire case study, the fault in system related to healthcare, process and accountability of the employees were discussed. However, the questions related to employee’s prospect of the reason to making mistake was not discussed. There is a possibility that the employees of the radiology department worked for extra hours that made them fatigue and stressed that increased the chances of fault in the process (Lerman et al., 2012).

References

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Bellows, M., Kovacs Burns, K., Jackson, K., Surgeoner, B., & Gallivan, J. (2015). Meaningful and effective patient engagement: what matters most to stakeholders. Patient Experience Journal, 2(1), 18-28.

Berger, Z., Flickinger, T. E., Pfoh, E., Martinez, K. A., & Dy, S. M. (2013). Promoting engagement by patients and families to reduce adverse events in acute care settings: a systematic review. BMJ Qual Saf, bmjqs-2012.

Bratianu, C. (2013). Nonlinear integrators of the organizational intellectual capital. In Integration of Practice-Oriented Knowledge Technology: Trends and Prospectives (pp. 3-15). Springer, Berlin, Heidelberg.

Carayon, P., Wetterneck, T. B., Rivera-Rodriguez, A. J., Hundt, A. S., Hoonakker, P., Holden, R., & Gurses, A. P. (2014). Human factors systems approach to healthcare quality and patient safety. Applied ergonomics, 45(1), 14-25.

Greig, G., Entwistle, V. A., & Beech, N. (2012). Addressing complex healthcare problems in diverse settings: insights from activity theory. Social Science & Medicine, 74(3), 305-312.

Lee, C. S., Nagy, P. G., Weaver, S. J., & Newman-Toker, D. E. (2013). Cognitive and system factors contributing to diagnostic errors in radiology. American Journal of Roentgenology, 201(3), 611-617.

Lerman, S. E., Eskin, E., Flower, D. J., George, E. C., Gerson, B., Hartenbaum, N., … & Moore-Ede, M. (2012). Fatigue risk management in the workplace. Journal of Occupational and Environmental Medicine, 54(2), 231-258.

Ogdie, A. R., Reilly, J. B., Pang, M. W. G., Keddem, M. S., Barg, F. K., Von Feldt, J. M., & Myers, J. S. (2012). Seen through their eyes: residents’ reflections on the cognitive and contextual components of diagnostic errors in medicine. Academic medicine: journal of the Association of American Medical Colleges, 87(10), 1361.

Underwood, P., & Waterson, P. (2014). Systems thinking, the Swiss Cheese Model and accident analysis: a comparative systemic analysis of the Grayrigg train derailment using the ATSB, AcciMap and STAMP models. Accident Analysis & Prevention, 68, 75-94.

Wahr, J. A., Prager, R. L., Abernathy, J. 3., Martinez, E. A., Salas, E., Seifert, P. C., … & Sanchez, J. A. (2013). Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association. Circulation, CIR-0b013e3182a38efa.