Malpractice v. Performance Improvement Process

Case Study, Chapter 2, p. 35 Wildcat Hospital is a 400-bed acute-care facility with a wide range of services. Dr. Jones is a Cardiothoracic Surgeon at the facility and has been practicing in the area for the past six years. Dr. Jones is performing a coronary bypass procedure on a 59-year-old patient. Although the procedure is going well, it took more time than usual to complete because, prior to beginning, the Anesthesiologist needed extra time to ensure a safe experience with the anesthesia due to the patient’s asthma and sleep apnea. The operating rooms at Wildcat Hospital have been especially busy lately with a high number of unexpected trauma surgeries along with the already busy schedule the operating room tends to have. Dr. Jones is preparing to finish the procedure and “close up” the patient when he notices another physician standing at the window in the door leading into the operating room. The physician is a seasoned physician that has been at the hospital for several decades. The physician not only looks through the window at Dr. Jones but lifts his arm and taps on his watch as a way to tell Dr. Jones that his surgery time has gone past what is scheduled. Although Dr. Jones is a confident and competent surgeon, this experience rattles him a little and he finds himself somewhat distracted by the other physician’s behavior. He lets himself become a little “short-fused” with the staff in the room and begins to speed up his work, pressuring the other staff. Dr. Jones has the patient return to his office with pain and issues in his incision. After further workup, it is determined that a sponge was left in during the procedure. Case Study Questions: 1. What issues do you see with this case? 2. How could this situation have been prevented? From Figure 2. 2, (p. 25 of textbook): Organization-wide PI process, what can be applied to prevent this from happening again? 3. How does the role of mindfulness play in this case?

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