Case Report: Application of Quality and Safety Concepts

Case Report: Application of Quality and Safety Concepts

Case Report: Application of Quality and Safety Concepts


Making errors is considered as part of normal human behaviour but can either occur intentionally or out of an accident. In the medical sector, making errors is inevitable and has serious unintended consequences not only to patients but also to the entire industry. For instance, in 2017, 59% of victims of surgical errors in America encountered temporary injuries while 33 percent developed permanent injuries as 6.6 percent led to wrongful death (Fruggiero et al., 2018). In addition, over $1.3 billion was paid as claims of surgical malpractice in 2017 in the United States of America alone. When errors pose significant risks in a health setting as, they raise concerns on how to address them (Cohen et al., 2017). However, despite a large percentage of errors in the health sector little research exist to establish the causes and mitigation strategies. One error of significant concern relates to those associated with surgical procedures.

Ever since the discovery of surgery, different approaches have been used to locate sites for operations and guidelines on successful therapy. It has also served as one of the therapeutic options to address different ailments. However, surgery is considered as one of the dynamic specialties in healthcare with a milieu of unintended mishaps that are likely to occur. Some of these accidents are known and can be avoided while others cannot be predicted. Research studies by GarcíaSánchez et al(2017) affirm there are about 17 million surgeries every year in the United States of America. The study further indicates that every week, surgeons are 39 times likely to leave foreign materials inside the body of patients. Likewise, surgeons are 20 times probability to perform wrong surgical procedures. Similarly, the study established that surgeons are 20 times likely to conduct procedures on the wrong part of the patient’s body weekly.

Studies by Batley et al(2015) reports that 50% of all surgical mistakes are related to human errors. The latter was due to communication and poor coordination of teamwork. However significant errors emerged due to wrong judgment, fatigue and lack of attention due to mental pitfalls. Occasionally, surgical procedures are performed within a short time and require accurate decision making to address safety and quality to patients. Within this time, there are known risks that can be solved but not all decisions on incisions result in successful procedures.

Patients all over the world have a right to high-quality care and safety is one aspect that must be addressed by health professionals.

The idea that not all surgical procedures become successful is one aspect that has rallied several conversations in the United States of America. Debates have ensued as to whether some of the errors emanate from the negligence of the surgeons and health staff in the operating room or due to faulty equipment (Broadbent, 2017). Notably, practicing surgical procedures in the current time embraces new technical innovations that have seen the development of robotic-assisted surgeries. However, controversies on costs, safety, and effectiveness in the use of robotic surgeries have altered its implementation to optimize quality outcomes for patients. Notably, with the dynamics in the health industry, the error goalposts in surgical procedures continue to move and surgeons must be vigilant not to deflect from providing quality and safe care to patients by embracing the use of robotic-assisted surgeries. Therefore, the purpose of this paper is aiming to address a problem with a case summary, a proposed solution from a theoretical approach, along with an instrument for evaluation and end with a conclusion.

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Brief Literature Review

Errors occur in the life of every person whether at home, place of work or even when one walks along the road. In a clinical setting, care providers and patients encounter errors of different magnitudes. Fruggiero et al. (2018) analyse the implications of errors in hospitals and reports its association to poor quality health which in turn affects the lives of people directly or indirectly. Cohen et al. (2017) on the other hand affirms technology in patients continually becomes complex and is changing healthcare approaches especially in nursing care.

In a retrospective study, Batley et al. (2015) examine the nature and implications of human error during surgical procedures. Through an account of medical literature, the article establishes the “blame and shame culture” which is predominant in the line of surgical practice especially in the event of an occurrence of an error. The author opines on the need to examine the nature of human error predominant in surgical practice in order to assess their consequences on the quality of surgery in a health care practice. The article advocates for teamwork, advancement in health information technology and the use of evidence-based practice as options for the safest possible surgical procedures.

Broadbent (2017) undertakes prospective trials on medical errors associated with human negligence. By using twenty studies in Italy, the article reports that health-care related errors affect 8% to 12% of patients admitted in the wards. However, the author suggests that about 50% to 70.2% of the errors in hospitalized patients can be prevented through a comprehensive and systematic approach that focuses on patient safety.

Cohen et al. (2017) investigate the application of DaVinci robotic system to perform surgical procedures for patients scheduled for laparoscopy; ten patients undergoing the procedure were examined for two months in Germany. The research entailed laparoscopic-assisted surgeries administered by robots and operated by trained surgeons. The purpose of the study was to ascertain how robotic surgeries were significant in addressing Human Error Probability (HEP). The outcome revealed the DaVinci robotic system was the “keyhole” that allowed surgeons to conduct operations with greater precision and accuracy by using small incision tools that were minimally invasive. Moreover, the outcome indicated that robotic systems were safe for laparoscopy as they can be used for reconstructive phase of surgeries due to less bleeding when compared to open surgeries.

A study by Casillas et al. (2014) is a retrospective trial experiment to examine how the use of robotic-assisted laparoscopy reduced the use of morphine and other opioids in pain management. The study used 60 patients scheduled for robotic-assisted laparoscopy for radical prostatectomy. Participants were enrolled in two groups. As for Group I, a total of 30 patients was administered with pre-emptive pregabalin, 975mg paracetamol, and calecoxib two hours before the surgery; 30 patients in Group II received post-operative intravenous ketorolac, 325mg paracetamol, and oxycodone. The groups also received morphine administration which was examined intra- and post-operatively. The findings from the studies revealed a reduction in morphine administration for patients in Group I. However, there were no changes in the length of stay or a reduction in postoperative creatinine levels in patients for both the groups.

Description of the Case/Situation/Conditions explained from a Theoretical Perspective

In an operating room (OR), the aspect of “to err is human” could potentially emerge as a matter that determines life or death for a patient. The premise implies that human mistakes in surgeries are compounded by the premise that no level of perfection can be achieved due to unknown errors in the operating rooms. Through an analysis of surgeries by Batley et al(2015), it was established that half of the errors in OR result from deficiencies in human performance. Human error in the surgical setting is considered inevitable and focus should aim at reducing the avoidable mistakes in a bid to optimize quality care to patients.

In the OR, mistakes that result from human performance deficiencies include violation of rules and protocols of surgeries, poor communication, execution, teamwork and lack of proper planning which affects problem-solving. A study conducted by Cohen et al. (2017) reports that half of the performance deficiency for human in the OR were cognitive errors which include lack of recognition, lack of attention in addition to cognitive bias. Additionally, the study affirmed that human mistakes in surgeries related to teamwork, system-related safety and communication were lower when compared to errors of human factors. The study suggests that every human is imperfect and requires extra training to mitigate the risks of surgical errors. Nonetheless, a human is subject to exhaustion and fatigue which readily alter their judgment during operation.

The United States of American performs close to 17 million surgical procedures annually (Broadbent, 2017). However, the report on the frequencies of unintentional damage, challenges related to the cause of these damages as well as the understanding of the long-term impacts of these mistakes is scanty. A research was conducted to examine the unintentional errors that occur during knee surgery for patients with osteoarthritis. The study conducted in Australia examined the potential errors in knee arthroscopy as performed 93 surgeons who were also enrolled as participants in the research. The outcome indicated that 49.5% of errors related to the attitude of surgeons and this resulted in unintentional damage to articular cartilage. The latter is the tissue that covers the open ends of the joints on the knee and this affected ten patients in the OR for knee arthroscopy. 34.4% of the surgeons interviewed reported that mistakes in human errors during surgeries affect one in every five procedures (Fruggiero et al. 2018). However, 7.5% of surgeons in the study affirmed that unintentional damage to the articular cartilage occurs in every surgical procedure and later in life may develop osteoarthritis.

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The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.

Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.

If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.

I do not accept assignments that are two or more weeks late unless we have worked out an extension.

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Communication is so very important. There are multiple ways to communicate with me:

Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.

Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

Important information for writing discussion questions and participation

Welcome to class

Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to

I strongly encourage that you do not wait until the very last minute to complete your assignments. Your assignments in weeks 4 and 5 require early planning as you would need to present a teaching plan and interview a community health provider. I advise you look at the requirements for these assignments at the beginning of the course and plan accordingly. I have posted the YouTube link that explains all the class assignments in detail. It is required that you watch this 32-minute video as the assignments from week 3 through 5 require that you follow the instructions to the letter to succeed. Failure to complete these assignments according to instructions might lead to a zero. After watching the video, please schedule a one-on-one with me to discuss your topic for your project by the second week of class. Use this link to schedule a 15-minute session. Please, call me at the time of your appointment on my number. Please note that I will NOT call you.

Please, be advised I do NOT accept any assignments by email. If you are having technical issues with uploading an assignment, contact the technical department and inform me of the issue. If you have any issues that would prevent you from getting your assignments to me by the deadline, please inform me to request a possible extension. Note that working fulltime or overtime is no excuse for late assignments. There is a 5%-point deduction for every day your assignment is late. This only applies to approved extensions. Late assignments will not be accepted.

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Plagiarism is highly prohibited. Please ensure you are citing your sources correctly using APA 7th edition. All assignments including discussion posts should be formatted in APA with the appropriate spacing, font, margin, and indents. Any papers not well formatted would be returned back to you, hence, I advise you review APA formatting style. I have attached a sample paper in APA format and will also post sample discussion responses in subsequent announcements.

Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.

I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!

Hi Class,

Please read through the following information on writing a Discussion question response and participation posts.

Contact me if you have any questions.

Important information on Writing a Discussion Question

  • Your response needs to be a minimum of 150 words (not including your list of references)
  • There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
  • Include in-text citations in your response
  • Do not include quotes—instead summarize and paraphrase the information
  • Follow APA-7th edition
  • Points will be deducted if the above is not followed

Participation –replies to your classmates or instructor

  • A minimum of 6 responses per week, on at least 3 days of the week.
  • Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
  • Each response needs to be at least 75 words in length (does not include your list of references)
  • Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
  • Follow APA 7th edition
  • Points will be deducted if the above is not followed
  • Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
  • Here are some helpful links
  • Student paper example
  • Citing Sources
  • The Writing Center is a great resource