Description:
Unit 3: Week 3 (3/25 - 3/31) - Real Life Case Study
Real-Life Case Study
In February 2003, at Duke University Medical Center, Jessica Santillan who was 17 died after undergoing heart-lung transplantation because of a simple mistake. The circumstances of this case were particularly poignant. Her family and the wider community had gone to extraordinary lengths to make her operation possible. Jessica had been brought to the United States by her father, a truck driver from Guadalajara, Mexico to seek treatment for her condition. She suffered from a severe congenital heart problem, and was disabled to the extent that she fainted on any exertion. The only treatment for her condition was a heart-lung transplant. Her family begged in the streets to raise funds for Jessica's procedure until a North Carolina businessman adopted her cause. Money was then raised by a grass-roots foundation by building houses with donated materials and selling them....CLICK HERE TO GET MORE ON THIS ESSAY!!!
On the evening preceding the operation, there were considerable logistical difficulties in obtaining the organs. They were eventually implanted, but, after a short time it became apparent that they were not functioning well. The transplant coordinator then called to inform the team that the transplanted organs were incompatible: Jessica's blood type was O and the donor's was A. Jessica spent two weeks in intensive care, critically ill. She underwent a second heart-lung transplant, but to no avail. On February 22 she was pronounced brain dead, and life-support was withdrawn....CLICK HERE TO GET MORE ON THIS ESSAY!!!
During this period there was a full disclosure of the facts by Duke Medical Center. The chief executive officer admitted publicly that an error had been made. A chronology of the events was posted on a web site. Public apologies were made. Subsequently, a root cause analysis was undertaken, and changes instituted into transplant procedures at Duke, with a view to reducing the likelihood of recurrence of this type of tragic event.....
(Excerpt taken from Safety and Ethics in Healthcare: a Guide to Getting It Right by Runciman, Merry and Walton)
Respond to the following questions:
Was this an example of the good use of healthcare resources? How did things go wrong? How was such a basic requirement--to check the compatibility of the blood groups--overlooked by such highly skilled, highly motivated and well intentioned professionals? Should anyone be blamed or was this a system failure? How can errors of this sort be avoided? Was the hospital's response appropriate? Using your knowledge on root cause analysis, please develop a cause-and-effect diagram for this case and develop an Action Plan. What do you think Duke changed to prevent events like this from happening again (policies, procedures, etc.)?
Real-Life Case Study
In February 2003, at Duke University Medical Center, Jessica Santillan who was 17 died after undergoing heart-lung transplantation because of a simple mistake. The circumstances of this case were particularly poignant. Her family and the wider community had gone to extraordinary lengths to make her operation possible. Jessica had been brought to the United States by her father, a truck driver from Guadalajara, Mexico to seek treatment for her condition. She suffered from a severe congenital heart problem, and was disabled to the extent that she fainted on any exertion. The only treatment for her condition was a heart-lung transplant. Her family begged in the streets to raise funds for Jessica's procedure until a North Carolina businessman adopted her cause. Money was then raised by a grass-roots foundation by building houses with donated materials and selling them....CLICK HERE TO GET MORE ON THIS ESSAY!!!
On the evening preceding the operation, there were considerable logistical difficulties in obtaining the organs. They were eventually implanted, but, after a short time it became apparent that they were not functioning well. The transplant coordinator then called to inform the team that the transplanted organs were incompatible: Jessica's blood type was O and the donor's was A. Jessica spent two weeks in intensive care, critically ill. She underwent a second heart-lung transplant, but to no avail. On February 22 she was pronounced brain dead, and life-support was withdrawn....CLICK HERE TO GET MORE ON THIS ESSAY!!!
During this period there was a full disclosure of the facts by Duke Medical Center. The chief executive officer admitted publicly that an error had been made. A chronology of the events was posted on a web site. Public apologies were made. Subsequently, a root cause analysis was undertaken, and changes instituted into transplant procedures at Duke, with a view to reducing the likelihood of recurrence of this type of tragic event.....
(Excerpt taken from Safety and Ethics in Healthcare: a Guide to Getting It Right by Runciman, Merry and Walton)
Respond to the following questions:
Was this an example of the good use of healthcare resources? How did things go wrong? How was such a basic requirement--to check the compatibility of the blood groups--overlooked by such highly skilled, highly motivated and well intentioned professionals? Should anyone be blamed or was this a system failure? How can errors of this sort be avoided? Was the hospital's response appropriate? Using your knowledge on root cause analysis, please develop a cause-and-effect diagram for this case and develop an Action Plan. What do you think Duke changed to prevent events like this from happening again (policies, procedures, etc.)?
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