Who was affected and how did it influence quality service delivery at this facility?


The healthcare business is a fancy system that requires consideration to element and the power to adapt to altering circumstances. Regardless of efforts to enhance affected person security and high quality of care, medical errors proceed to be a major problem in healthcare. This report presents a real-world instance of a healthcare error that impacted affected person security and gives an evaluation and suggestions for enchancment.

State of affairs Description

The healthcare facility concerned on this incident was a big educating hospital positioned in a significant metropolitan space. The error occurred within the hospital’s emergency division, the place a affected person was admitted with chest ache and shortness of breath. The affected person was seen by a doctor who ordered a chest X-ray and an electrocardiogram (ECG). Nevertheless, as a consequence of a communication breakdown, the ECG was not carried out.

The affected person was later identified with a pulmonary embolism, which was recognized on the chest X-ray. The affected person’s situation worsened, they usually had been transferred to the intensive care unit (ICU) for additional therapy. Sadly, the delay in prognosis and therapy resulted within the affected person’s loss of life.

Affect on High quality Service Supply

This error had a major influence on high quality service supply on the hospital. The affected person’s loss of life not solely had a profound impact on their household but in addition on the hospital employees. The hospital’s status was tarnished, and affected person belief within the hospital was undermined. Moreover, this incident might have contributed to employees burnout and decreased job satisfaction, which might finally have an effect on the standard of care offered to sufferers.

Dealing with of the Occasion

The hospital’s leaders and inner stakeholders took this occasion very severely and performed an inner investigation to determine the basis reason for the error. The investigation revealed that there was a breakdown in communication between the doctor and the nursing employees, which led to the ECG not being carried out. The hospital’s leaders carried out a number of modifications, together with bettering communication protocols and rising coaching for employees on affected person security and high quality enchancment.

Exterior stakeholders, together with the affected person’s household and regulatory our bodies, had been additionally notified of the incident and the steps being taken to deal with the difficulty. The hospital’s leaders acknowledged the significance of transparency and labored to take care of open strains of communication with all stakeholders.

Suggestions for Enchancment

To stop this case from reoccurring, the hospital ought to think about the next suggestions:

  1. Standardize communication protocols: To stop communication breakdowns, the hospital ought to develop standardized communication protocols that clearly outline roles and tasks for healthcare suppliers.
  2. Enhance coaching on affected person security and high quality enchancment: Employees coaching on affected person security and high quality enchancment ought to be elevated to make sure that all employees members have the information and expertise essential to determine and handle potential errors.
  3. Implement a top quality enchancment program: A top quality enchancment program ought to be carried out to determine and handle systemic points which will contribute to errors. This program ought to embody common monitoring of affected person outcomes and suggestions from employees and sufferers.
  4. Develop a tradition of security: To advertise a tradition of security, the hospital ought to encourage open communication and reporting of errors. Employees ought to really feel snug reporting errors with out worry of retaliation.


Medical errors proceed to be a major problem in healthcare, and it’s essential that healthcare organizations take proactive steps to stop errors from occurring. The incident described on this report demonstrates the significance of efficient communication, employees coaching, and a tradition of security in stopping errors. By implementing the suggestions offered, the hospital can enhance affected person security and high quality of care whereas additionally rebuilding belief with sufferers and the neighborhood.

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