Case Study Example: Medication Errors Reporting

A community memorial hospital faces challenges in medical reporting which result in the hospital's medical errors. These problems include timely incident reports and incomplete reports to the supervising officers in the hospital. A joint commission finds these problems resulting from medical reporting process. The medical process used in making reports is the main problem; it is not followed to the letter by the hospital staff. The CEO of the hospital tasked Frances Ballentine, who is the VP of nursing services, to find a solution to the medical errors discovered by the task force. She was given six months to investigate and come up with a good solution to this problem. Despite knowing and understanding the challenges of medical reporting, Ms. Ballentine decided to investigate a process which would amount to the solution. Ms. Ballentine was not experienced in the medical errors reporting but understood the challenges that come with the case study of medical errors. However, she followed the necessary planning strategies to solve the reporting problem in the hospital.

The initial discovery of Miss Ballentine was that the process used to report medical errors was not consistently applied. The process only appeared on the hospital's manuals, but the staff had little knowledge on how to apply the process in cases of medical errors. Another problem discovered by Frances Ballentine was that more than 20% of the incidences that occurred in the hospital were not reported as recorded. Some other reports were incompletely filled while others were not timely recorded. These inconsistencies resulted in the high number of medical errors witnessed in the community memorial hospital. To further unfold the mystery Frances had to conduct a thorough investigation on the matter where she brought in the director of Quality improvement, Ally Ray to assist her.

Miss Ballentine used a continuous Quality improvement process to investigate the medical errors problems. She consulted Ally Ray who advised her to form a quality improvement taskforce which would oversee the process of solving medical problems. This team was to analyze the report, offer recommendations and implement solutions to medical reporting problems. The task force used FOCUS (find, organize, clarify and understand the problem) framework to guide them in carrying out their mandate. Frances identified the initial process which they sought to improve and implement in medical reporting. The strategic plan needed to be identified and executed by the MEQI project guided by the findings of Frances Ballentine. They had to study data and understand the variety of problems they faced to come up with solutions. They participated in exercises where they compared data from one department to another on different days. Frances used fishbone diagram to determine the root course of medical errors in the hospital where the MEQI members were to vote for what they thought was a problem. The strategy was aimed at understanding the core capabilities of each departmental leadership. To come up with a developmental strategy, one has to study the strengths and weaknesses of a process like Ballantine did; she tasked all the six units of the hospital to create separate checklists of medical errors for a month. The intention was to understand all the variations in different departments and what each required in reducing medical errors.

However, the medical error problem was not solved immediately; the problems mostly identified were vague policies, nurses unsure of reporting procedures and vague forms which lead to medical errors. These problems require a long along the process to solve, the MEQI team after understanding the problems they embarked on the implementation of the solutions. They used the PDCA framework which required planning, checking and executing the solutions. The solutions were to be implemented in phases at different departments. The human resource team, the nurse managers and all other staff of the hospital were coordinated by the quality improvement team in implementing the recommended solutions. They ensured that policies were implemented and revised to reduce the medical errors. They were to change the policies, revise the forms and offer training to the staff. All this was implemented by the human resource team as tasked by QI taskforce. Everybody was brought on board by Frances Ballentine to ensure reporting of medical errors rose to 95%. The CEO was to talk to the nurse managers to ensure they adhered to the standard rules of reporting medical errors. By October reporting of medical errors rose up to 96% but remained low on the weekends.

In correction of the reporting problems of medical errors, Frances should engage directly with the staff rather than the leaders. This will break the barrier in communication between the two parties and improve the reporting rate. At the same time to emphasize the importance of reporting medical errors, the sentence ought to be applied to anyone who has been found in violation of the reporting process. This will make staff realize the importance of reporting medical errors to the relevant authorizes. In the same way, the heads of departments should be liable for ensuring the reporting process is followed to the letter since they happen to be the immediate supervisors in their respective areas.

In the study there were motivational problems, this also led to reporting of medical errors in the hospital. The staff did not understand well why they had to report all the medical errors. If motivation had been given to them, there would adequate reporting of the medical errors. At the same time, despite doing good work, MEQI was dissolved. They would have been left to make more policies which would improve the medical errors reporting in the hospital. The quality improvement director, Ally Ray moved on leaving Frances Ballentine to take care of the remaining problem. This was a mistake since they both played an essential role in ensuring that everything went on well. The CEO did not understand that it was not a one-person job to ensure maximum medical errors are reporting. However, Frances was left to take end the problem without the help of MEQI team.

Despite Frances lacking the necessary experience to conduct the study, the CEO went ahead to give her the role of solving medical errors problem. This is a leadership problem that is experienced in this hospital. At the same time, the CEO dissolved quality improvement team without completing their task. Despite noting the weekend reporting problem, the QI team was disbanded. However the best part of the hospital has no leadership problems, they are both coordinated and consult each other in cases of problems. Frances was left to monitor the situation of medical errors reporting through checklists which gave her the full leadership of medical errors reporting.