In the following, the first errors have been presented and identified in the Coroner’s Report. These errors emerged due to the lack of coordination and the inability to use the software for medication. The hospital might have introduced TrakCare without proper planning. However, a complete list of errors is in the following that has led to the death of Paul.
Error in reaching consensus at the workplace:
The case study notes that errors occurred in the workplace during the treatment of Paul. Some users were not in favor of the application of TrakCare. They were initially dissatisfied. It became the reason why the organization could not help responding to changes needed for the patient. The staff were not in line with each other, and the TrakCare was not supporting them to achieve common goals (Hwang et al., 2019).
Error with Training of Dr. Kim and lack of communication:
Another error was about the training of Dr. Kim. He noted that he did not have sufficient training in TrakCare. However, there was a lack of communication from him if he thinks inadequate training was provided to him. He could not say about his concerns or opinions regarding the use of TrakCare. It also caused the fall of the health of Paul. It was the first error in the treatment of Paul because of the lack of training to use TrakCare caused problems. After the adoption of the software, there was an increase in errors. It led to the death of the patient. Dr. Kim was not sure about the use of TrakCare, and he ignored many alerts as well.
Prescribing Error:
One of the errors identified in the Coroner’s report is the prescribing error. It occurred due to a failure of critical thinking. Persons involved did not exercise critical thinking abilities. This deficiency increased in its scale due to systemic deficiencies in nursing care. The error was quite comprehensive, which has affected the whole medical treatment of Paul. Dr. Kim could not pay attention to the content in the alert. Moreover, he also ignored the change in dosage and medication that was prescribed for Paul. This lack of follow-up and negligence led to mounting this prescribing error that has been discussed in the Coroner’s report. The prescribing error was the most prominent one that contributed to the death of Paul because a lack of consensus affected prescription for him (Jian-hui et al., 2019).
Analysis:
These errors are related to the process that is not consisted of and shared. Dr. Kim observed that the medical treatment of Paul was not in line with the prescribed method. He did not take appropriate action to rectify it. It is one of the reasons why this error kept on becoming larger. The doctor should have guided assistants and other staff members actively. Silence and negligence in providing medical care cannot be accepted. The prescription must be in light of the accurate health condition of the patient. Unfortunately, it was not the case here that resulted in a very dangerous consequence.
One of the reasons for these errors is related to TrakCare that is the electronic method of managing treatment. It should have acted to take everyone on-board and keep things on track. The staff supervising Paul, and the hospital did not have a consensus on it. It calls for the need to link human effort with technology because technology alone cannot solve problems. TrakCare is the method that should guide the medical process, but it became the reason for the error. It was due to the lack of alignment between technology and human efforts. It highlights the issue of the lack of integration prevalent at the hospital.
The bottom line of these errors is the lack of preparation for treating a patient. The hospital changed operations and medical treatment, but there was no guidance from the top management. It allowed everyone to choose his course of action. It deteriorated the health of the patient because of a lack of standard operating procedures. Prescription error, error with training or use of TrakCare, and the lack of consensus are symptoms of failing practices and processes prevalent in the hospital. The analysis calls for getting together in making efforts to treat a patient (Manias et al., 2015).
References
Hwang, J.-I., Kim, S.W. & Ho, J.C., 2019. Patient Participation in Patient Safety and Its Relationships with Nurses’ Patient-Centered Care Competency, Teamwork, and Safety Climate. Asian Nursing Research, 13(2), pp.130-36.
Jian-hui, Y., Yu-fang, L., Wu-bin, L. & Wu, W., 2019. Prescribing errors in electronic prescriptions for outpatients intercepted by pharmacists and the impact of prescribing workload on error rate in a Chinese tertiary-care women and children’s hospital. BMC Health Services Research, 19, pp.1-11.
Manias, E. et al., 2015. Barriers and enablers affecting patient engagement in managing medications within specialty hospital settings. Health Expectations, 18(6), pp.2787-98.
