Clinical Decision Making

Clinical Decision Making

[Name of the Institute]

Clinical Decision Making

Introduction

The healthcare industry of the United Kingdom is evolving with time as the health care demands are escalating by an appalling rate. Not only is the increasing health care requirement affecting the economy, but it also has grave consequences on the health care providers and ultimately the patients. Since the patient and health care provider ratio are not in equilibrium, therefore, healthcare industry poses a risk on the patients. These risks are accidental in nature and can vary from insignificant medical errors to grave permanent disability or death.An error is the inability to execute a premeditated action as planned. On the other hand, an adverse event is an error of the medical management which caused extended hospitalization or disability (WHO, 2010).

It is the aversion and prevention of an adverse event or from the impairments caused by health care, such as “errors,” “deviations,” and “accidents.” In order to provide patient safety, it requires the components of the system to work together, rather than blaming the individual, device, or department. Furthermore, patient safety is a component of health care quality.

Case Study (The Swiss Cheese Model)

During the late night shift on October 7th, 2010, a 21-year-old patient was admitted in a hospital for her delivery. During care, one of the newly inducted nurses gave her an infusion which was planned for the epidural route and was linked to the patient's peripheral IV line. Within no time, the young patient underwent cardiovascular failure and died. On the other hand, her baby was saved by a cesarean section by the medical team on duty.

The Swiss Cheese model is used in the risk analysis and risk management of human systems (Carol, 2004, pp.74-75). It proposes that every system is like a stack of slices of Swiss cheese. Each slice is defensive layer for the other slice. Each slice of cheese represents a different level. Errors occur in every system, therefore, the holes on the slices denote the individual weaknesses in every level. All the holes are opportunities for a process to fail and if the issue occurring at each level is not addressed, then a disastrous error is likely to take place.

In the above scenario, the error occurred at the initial level due to the unavailability of protocols for administration of the epidural, then due to similar packaging of two different drugs and confusion of the nurse led to the miscommunication with the physician, and as a result, patient death occurred.

Source : http://patientsafetyed.duhs.duke.edu/module_e/swiss_cheese.htm

Active errors occur by the healthcare provider directly overlooking the case, in the case study, the direct error is the nurse. Latent errors are the errors which had no direct impact on the error, such as the poor system design. In the case study, the similar packaging of medication, placed in close proximity causing confusion is the error.

Source : http://www.who.int/patientsafety/research/ps_online_course_session1_intro_1in1_english_2010_en.pdf

Fishbone Technique

The Fishbone analysis technique acts as a guide to identify and distinguish the probable causes of a medical error ...