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Project 7-1: Classify Patient Incidents According to Policy

The following activity is found in your Health Care Quality Management Student Workbook, page 43. The workbook provides patient incident report forms completed by staff in the healthcare organization. This primary source of information on patient safety will be used to analyze the incidents according to level of severity. The following policies define the three categories of severity

Policy on Level I Event: An incident that resulted in patient death or serious short or long-term (6 weeks or more) disability or harm
Policy on Level II Event: An incident that resulted in minimal short-term patient disability or harm
Policy on Level III Event: An incident that could have resulted in patient death, disability or harm but did not, either by chance or through timely intervention
Read the ten patient incident descriptions from your workbook. For each incident, indicate by policy definition how it should be categorized. If the description contains insufficient information to allow it to be categorized, indicate that "more information is needed." If you are not familiar with the terminology used in the incident descriptions consult a medical dictionary.

Report your findings by creating a tabular report that provides the following information to the risk management department. Remember to apply all guidelines/formatting rules when creating the tabular report. You may need to refer back to Chapter 4 of your textbook.

Incidents reported (incident 1, incident 2...)
Level of events including "more information is needed"
A total for each level of event that occurred

Incident # 1
The nursing staff was providing a patient with routine a.m. care. This consisted of showering the patient in the shower room on the ward. The patient was being washed while seated in a chair when he slid off the chair hitting his face, hip and shoulder. The patient was examined by the doctor at 0755 and transferred to the emergency department (ED) for further evaluation. The ED physician ordered x-rays No fractures were found however he did have some minor contusions. The patient was returned to the ward where neurological checks were initiated per policy and reported as normal.
Incident # 2
A 61-year old female was admitted for GI bleeding and underwent hemicolectomy. She was put on a ventilator postoperatively and transferred to the surgical intensive care unit. On the 8th post-operative day,while still on the ventilator, the patient developed copious respiratory secretions and became restless and agitated. She was sedated with Diprivan which seemed to improve her condition. On the 9th postoperative day two nurses turned the patient on her side for a bath. The patient started coughing and was noted to have copious secretions. A respiratory therapist was summoned to assist the nurses who had already started to suction the patient's secretions. The respiratory therapist checked the patient's endotracheal tube and found it to be in the oropharynx rather than the trachea. The tube was removed and respiratory therapist attempted re-intubation but was not successful. A "code red" (cardiac arrest) was called to alert professional staff that help was needed. A certified nurse anesthetist arrived within minutes and attempted to reintubate the patient but he could not visualize the patient's vocal cords (patient had very large tongue). Another attempt was made with a smaller tube and this was also unsuccessful. The third reintubation attempt was successful, however the patient could not be resuscitated and she expired.

Incident # 3
A 2-yr-old boy with retroperitoneal rhabdomyosarcoma was scheduled to undergo abdominal MRI. Anesthesia was provided by an anesthesiologist/nurse team with experience in anesthesia for MRI. After a check for removal of all ferromagnetic materials and of the MRI compatible ventilator, anesthesia was induced and maintained via a closely fitting facemask in the spontaneously breathing child using sevoflurane-nitrous oxide in 50 % oxygen , and vital signs were monitored using MRI - safe equipment (graphite electrocardiogram fiberoptic pulse oximetry, end-expiratory carbon dioxide, noninvasive blood pressure). When a low level of sevoflurane was noted in the vaporizer, the nurse was asked to refill it. However, because a refill bottle of sevoflurane was not immediately found, the nurse instead carried a portable sevoflurane vaporizer from the induction room into the MRI suite. Neither she nor the anesthesiologist considered that the almost empty sevoflurane vaporizer in the MRI suite was fixed to the ventilator and hence could not be replaced at all. When the nurse put the vaporizer on the examination table, it was rapidly attracted toward the MRI's 1.5-T magnet. It was only by the force of four hands that the vaporizer could be directed to strike against the gantry instead of flying directly into the magnet, where might have hit the child. The table with the sleeping child was rapidly moved out of the gantry avoiding further danger. Fortunately, neither the child nor the MRI machine was harmed, and the examination went on without further complications after excluding MRI damage and refilling the fixed vaporizer.

Incident # 4
A 59-year old patient with chronic obstructive pulmonary disease was ordered by his physician to have 100 % oxygen via facemask to correct his low PaO2 . The patient 's condition did not improve despite being on the 100 % oxygen for one hour . When the physician entered the patient 's room and moved the bed to begin intubation, it was discovered the patient was not on oxygen. Rather the oxygen tubing was attached to the medical air flow meter. Once the oxygen tube was connected to the oxygen flow meter the patient's condition improved. No further action was required.

Incident # 5
A 35-year old patient with left shoulder pain was seen in the physical therapy department for treatment of left shoulder and neck pain. His physician had prescribed several therapy modalities: hot packs, phonophoresis with ultrasound 1.5 watts per square centimeter and hydrocortisone 1 % for 8 minutes, massage, and interferential electrical stimulation. When the patient arrived for his first treatment, there were four other patients in the department at the time. He received electrical stimulation and hot packs to his left shoulder, followed by ultrasound. Following the patient's therapy the staff noted a reddened area on his left shoulder. The patient had been advised to report excessive heat from the treatment but he said he hadn't felt anything too hot. No treatment for the redness was deemed necessary and it was gone five days later when the patient came in for a second appointment.
Incident # 6
Two weeks after being admitted to the hospital's Alzheimer Unit, a 67-year-old patient wandered away from the facility. He was last seen at approximately 4:30 PM and was not in his room when dinner was delivered. The patient's nurse first looked for him in the outside hallways and other patient rooms. When he could not be located, the nurse contacted security. A full search of the building and grounds was initiated and this lasted about an hour. When the patient was not found, the local police department was notified of his missing status along with a physical description and information about his condition. The next morning the city police discovered the man wandering downtown (about 4 miles from the hospital) He was taken to the emergency department for evaluation where he was found to be dehydrated and suffering from pneumonia. He was admitted to the hospital for treatment and later transferred back to the Alzheimer Unit after six days of hospitalization.

Incident # 7
A laparotomy sponge was left in a patient who had undergone an esophagogastrectomy and thoracotomy At the end of the esophagogastrectomy, sponge counts done by the surgical nurse were reported as correct and the surgeon proceeded with the thoracotomy. At the end of the thoracotomy, the surgical nurse discovered the sponge count was incorrect by one sponge. A portable chest x-ray was done and erroneously read as negative by the surgeon (no radiologist was available in-house to interpret the x-ray). The next day the x-ray was read by a radiologist who found that a foreign object had been left in the patient's chest. The patient was returned to the operating room for removal of the sponge. According to the surgeon, this second procedure prolonged the patient's hospital stay by three days.
Incident # 8
A 9-year old girl was admitted to the pediatric unit with acute lymphocytic leukemia. This was a new diagnosis for this patient. Following six weeks of chemotherapy in the hospital, her immune system became extremely compromised. She was maintained in an isolation room for the last three weeks of therapy as her white count had dropped to very low levels. During week six in the hospital, the child spiked a fever to 104°F and became tachycardic. She complained of a new onset of pain in her head. This was reported to the oncologist immediately and cultures were obtained from blood, nasopharynx and spinal fluid. The spinal fluid and NP cultures grew Aspergillus fumigatus. Despite aggressive treatment, the child was taken to the operating room for removal of her left eye and cheekbone to prevent further damage from the Aspergillus. She was ultimately discharged home.

Incident # 9
A nurse on the medical ward tried to start an IV on a 72-year old patient, but was unsuccessful because the patient became agitated and moved around constantly. This occurred toward the end of the nurse's shift and she notified the incoming nurse that she had been unable to start the IV. The incoming nurse said she would try to do it as soon as she finished passing out medications to her other assigned patients When the incoming nurse finally got around to entering the room of the patient who needed to have the IV started, she discovered that the first nurse had not removed the tourniquet from the patient's arm. This was four hours after the original nurse had tried but failed to begin the IV. The patient's arm was swollen and there was some residual neurological and vascular damage that was still present at the time the patient was discharged.
Incident # 10
A female patient was scheduled for a phacoemulsification, cataract extraction, and an intraocular lens implantation on her right eye. Just prior to her operation, the anesthesiologist administered a lid block and partial retrobulbar injection to the patient's left eye even though her right eye was the operative site. The mistake was discovered by the surgeon before making an incision. The patient's right eye was anesthetized and surgically prepared and the surgery proceeded without incident.
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Staff Member
A month ago
Hi cangyufeiyi,

Sorry we couldn't answer your question. Do you mind updating us with the answer?

Thanks in advance!
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