Running head: ROOT CAUSE ANALYSIS OF CASE STUDY 14 1

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1 Running head: ROOT CAUSE ANALYSIS OF CASE STUDY 14 1 Root Cause Analysis of Case Study 14 Maria Arocha Angelo State University

2 ROOT CAUSE ANALYSIS OF CASE STUDY 14 2 Root Cause Analysis of Case Study 14 For this assignment I have chosen to discuss the root cause of death from The Big Picture: A Terminally Ill Patient in a Fragmented System. This case study focused on the deteriorating medical challenges that Fred Holliday faced. His wife, Regina Holliday, recalls the downfall of events that eventually led to his death. As I was reading through this case study, I was able to mark the areas of error as the story progressed. It is clear that these errors occurred from the time Fred Holliday was visiting his primary healthcare provider for a minor symptom up to the few weeks prior to his death. Although most of the problems in this case study occurred in different areas of the health care system, they all had one issue in common, communication. The communication issue between physician and patient began when Fred Holliday went to his primary care physician when he noticed he was increasingly fatigued. Regina recalls that Fred was in the process of losing weight by dieting and exercising. His physician immediately diagnosed him with high blood pressure and put Fred on medication for it. This scenario continued as Fred returned with complaints of chest and back pain resulting in his doctor prescribing him more medications to take. Fred and Regina still had not been given an explanation for any of the medical issues Fred had. It seemed that his physician was more concerned with treating Fred s symptoms rather than trying to research and correctly diagnose the cause of the symptoms. For several months Fred and Regina were left clueless about the status of Fred s health. Fred was never able to explain what the reasoning for a new medication was other than, that s what the doctor said (Barach, Haskell & Johnson, 2016). Fred and Regina were uninformed of his health status due to the lack of communication from the physician. According to a study from The Oschner Journal, around 75% of surgeons believed that they were communicating effectively with their patients while only 21% of their

3 ROOT CAUSE ANALYSIS OF CASE STUDY 14 3 patients were truly satisfied with the physician to patient communication (Ha & Longnecker, 2010). This means that approximately 79% of patients leave with no knowledge or understanding of what just occurred at their appointment. Fred and Regina were also a part of that statistic. The lack of education from the physician resulted in Regina doing what many other patients across the nation do as well; she went home and used the internet to educate herself on Fred s medical diagnosis. The internet can be helpful, but it should not be the primary method of education when it comes to a patient s health. To prevent patient harm, a physician should take the time to sit and discuss with their patient any new findings or areas of concern with them. It is important for physicians to remember that most patients do not understand medical terminology, and instead need an explanation in layman s terms. When Fred s doctor diagnosed him with high blood pressure, he should have provided him with education about what it is, causes, risk factors, and included Fred in the treatment plan that was specific to his health. This strategy would have provided education for Fred and given him the opportunity to voice any questions or concerns with his doctor. Another strategy that could be implemented is for the nurse to collaborate with the physician and patient. As nurses, we are often referred to as the patient s advocate and it is common for patients to feel more comfortable talking to the nurse. Prior to the doctor visiting, the nurse should ask the patient if they have any questions or concerns they would like to go over with the doctor; and prior to discharging the patient, the nurse should validate that all questions or concerns were answered. The physician s office number should be given to the patient and they should be encouraged to call or visit for any questions or concerns. Implementing these strategies will ensure that the patient feels educated and understands their health and treatment plan.

4 ROOT CAUSE ANALYSIS OF CASE STUDY 14 4 The other area that lacked communication was between the different hospitals. Regina recalls the difficulties of moving Fred to a hospital that specialized in oncology. It took two tries before they were able to find a decent hospital that could provide the care that was needed. However, due to the incomplete medical record that the initial hospital sent, the new hospital could not do anything for Fred. No dietary orders were given and pain medication was not available for him because those orders had not been included during the transfer. Studies have shown that the more physicians collaborating on a patient s care plan leads to the increased risk of errors due to poor communication (Taran, 2011). There are actions that can be implemented to prevent issues such as the ones Fred had to experience. The nurse who is caring for the patient prior to transfer should make sure that all orders and medical records are correct and complete prior to leaving. If there are any questions, the nurse should not hesitate to call the physician. Upon arrival to the new location, it would be best for the new nurse and healthcare team to receive an overall report of the new patient. They should ensure they have the correct patient, diagnosis, medications, and a complete medical record. Throughout this entire process, the patient should be able to voice any questions or concerns and have them answered thoroughly. When the patient s safety and health is the number one priority, there should be no errors that are caused by the lack of communication. A study from the McGill Journal of Medicine: MJM, stated that poor communication was one of the leading causes of preventable deaths in hospitals (Taran, 2011). A solid relationship between the physician and patient, along with other healthcare members is essential along with open communication. Implementing the strategies that I discussed will create a stronger work unit among the healthcare members, while maintaining the patient as a priority, and will also help create a safer environment while preventing patient harm and death.

5 ROOT CAUSE ANALYSIS OF CASE STUDY 14 5 References Barach, P., Haskell, H., & Johnson, Julie. (2016). Case studies in patient safety foundations for core competencies. Burlington, MA: Jones & Bartlett Learning. Ha, J. F., & Longnecker, N. (2010). Doctor-patient communication: A Review. The Ochsner Journal, 10(1), Taran, S. (2011). An examination of the factors contributing to poor communication outside the physician-patient sphere. McGill Journal of Medicine : MJM, 13(1), 86.