The case of Nick Francis investigates his death following surgery to remove a malignant lump. As told by his wife, Nick was initially expected to recover within a week and had a good chance of walking again. However, he was then diagnosed with Clostridium difficile, an infection of the intestines. Nick experienced symptoms such as diarrhea, nausea, and delirium, which ultimately resulted in his passing eight days after surgery (Canfield, 2016). Later, Nick’s wife discovered that his official autopsy results differed from the surgeon’s conclusion – Nick died from blood loss due to a gastrointestinal hemorrhage. As the patient’s wife investigated this incident, she discovered the system’s fragmentation, leading to many preventable errors.
The event poses many risks to the patient, family, and providers. First, the physical impact on the patient is clear – the patient passed due to the hospital failing to deal with the postoperative infection. The emotional impact on the family is substantial, as the patient’s wife lost her husband unexpectedly. Providers, especially caring nurses, were affected strongly, as they did not see death as a possible outcome. The financial risks for the patient’s family result in the funeral costs and the loss of a potential earner. For the providers, the event increases the risk of financial liability. Finally, organizational risks are a disturbance in hospital processes, lowered organization status, and decreased job satisfaction among providers.
One National Patient Safety Goal applicable to this scenario is to reduce the risk of healthcare-associated infections. The system failed Nick by not preventing the condition and not treating it to the best of the providers’ ability. Reviewing the case, it is apparent that the care was fragmented, as most providers had a limited understanding of the patient’s state. As evident from the nurses’ feedback, they did not know how Nick was treated by physicians, thus unable to notice his deteriorating health (Canfield, 2016). To prevent fragmentation, the hospital must improve interprofessional collaboration and increase patient and family participation. Furthermore, the organization needs to improve cause and effect analysis to distinguish between medical errors and fragmentation and use this tool for correcting care failures.
The lack of patient voice is a significant problem in healthcare, and patients and their families are often excluded from discussions about treatment. To involve patients in the care process, the hospital can provide patients with information. For example, patients and their caregivers may receive change-of-shift reports with an explanation from a provider that outlines the main improvements and problems and the patient’s overall state. In Nick’s scenario, the charting method seems ineffective in noting the deterioration in Nick’s condition. The main problem is the apparent lack of communication between providers, which can be solved using a problem-oriented approach involving input from all professionals caring for the patient.
Apart from improving the patient’s health, increased coherence in treatment can positively affect workplace satisfaction. Examining the selected case, one can see that nurses were devastated by Nick’s death and had to learn about it from unofficial discussions in the break room. Nurses who cared for Nick were also unaware of the issues he was experiencing before death, which means that the fragmentation of care left them confused and frustrated with the organizational approach. In contrast, increasing collaboration and ensuring transparency among practitioners can improve the providers’ knowledge and job satisfaction.
The relationship between providers and patients is also vital, as patients trust healthcare workers to help and understand their concerns. The lack of communication, dismissal of patient complaints by the providers, and the failure to ask the patient about his well-being erode this relationship and lead to conflict. Thus, transparent communication and care about the patient’s opinion build trust. One key point I learned from this case is that it is not enough for each practitioner to perform well, as healthcare requires teamwork and input from the patient, family, and provider to avoid preventable errors.
Reference
Canfield, C. (2016). A cascade of small events: Learning from an unexpected postsurgical death. In J. Johnson, H. Haskell, & P. Barach (Eds.), Case studies in patient safety: Foundations for core competencies (pp. 117-128). Jones & Barlett Learning.