Patient Safety Ace

Submit Assignment: Case 16: The Lewis Blackman Hospital Patient Safety Act: It’s Hard to Kill a Healthy 15-year-old
Case 16 (McLaughlin, Johnson, & Sollecito, 2011) outlines a fatal set of events that led to a legislative requirement requested by a patient advocacy group. It also indicates how regulatory enforcement is expected to be applied. Currently, the Physician’s Desk Reference notes that only one dose of ketorolac should be given postoperatively to children. What else could be done to avoid such a result in the future?
Upon reading Case 16 (McLaughlin, Johnson, & Sollecito, 2011), please answer the follow case assignment questions:
Where did the system fail Lewis and his family?
What were the system failures in Lewis’s care process related to
Preparation?
Organization?
Environment?
Technology?
Work tasks?
Healthcare provider?
Where in the process of care did incidents (errors, near misses, adverse events, and harm) occur?
What would be the elements of a more transparent informed consent process?
Were there opportunities in the process of care to repair physical damage? Relationship damage? Emotional damage?
What aspects of this incident will the new legislation cited in the case address? Which aspects does it not address and what else should be done to prevent recurrences of such incidents? If the nurses and residents had checked the references (PDR, for example) for ketorolac, what would they have found and how might it have affected Lewis’s treatment?
Your case report should be logically organized rather than just answers to the case questions. One possibility is as follows: Introduction, Analysis, Conclusions, and Recommendations. The main object of the report should be to analyze and justify your work, which requires a logical, coherent progression of relevant information that fully reveals the rationale behind the final recommendation.
Case study reports should consist of no more than two pages of typed text that provide the essentials, plus supporting exhibits if required. The papers should be typewritten and of required page length, double-spaced, 12 pt. font- Times New Roman, following APA format. Again all work must be individual and references must be cited.