Project #3642 - Health Care project


In this project you’ll identify risk reduction strategies that will result in a safer healthcare experience. A case study detailing an actual wrong site surgery sentinel event is used to illustrate the problematic processes. You’ll suggest ways of changing how things are done to prevent a similar event from happening at the hospital in the future.




1.      Read the article, “Reliability science: Reducing the error rate in your practice” by Elgert


2.      Read the case study event found below.


3.      Think about the seven reliability science tactics described by Elgert. Consider how these ideas for reducing errors can be applied to the different activities in the problematic system that resulted in a wrong site surgery. The tactics described by Elgert are:

·      Standardize the approach

·      Build decision aids and reminders into the system

·      Take advantage of pre-existing habits and patterns

·      Make the desired action the default, rather than the exception

·      Create redundancy

·      Bundle related tasks

·      Encourage teamwork, feedback and training


4.      In the spaces provided on the answer sheet found at the end of the assignment instructions, describe three different changes that could be made in the way things are done to prevent another wrong site surgery at the hospital in the case study. Be specific when describing the changes.


Each of your recommended changes should fall into one of Elgert’s seven reliability science tactics. Be as creative as you’d like – just be sure your innovative idea fits with a tactic discussed in Elgert’s article. Below is an example of a partially completed answer sheet (do not use the same answer in your responses).




Recommended Risk Reduction Action

Reliability Science Tactic


When the surgeon sees the patient in his office for the preop exam, the surgeon puts a bar-coded wrist band on the patient that indicates the type of surgery to be performed and the surgery site. The bar code can be scanned after hospital admission to confirm the type of surgery and the site.


Build decision aids and reminders into the system


5.      Upload only the answer sheet to the course site. Do not upload the instructions. Remember to put your name on the assignment.


The assignment will be graded according to completeness, compliance with assignment instructions, spelling/grammar and creativity.

Case Study Event


Wrong site surgery: left knee arthroscopy done instead of right knee arthroscopy. 


Event Timeline















Detailed Sequence of Events

Orthopedic clinic telephones hospital with reservation for left knee arthroscopy for 45 year old man. Clinic does not follow-up by faxing back the booking form as required by hospital procedure. 

Day of Surgery


Patient arrives for registration and procedure. OR schedule and face sheet indicates patient is scheduled for left knee arthroscopy. History and physical (H&P) exam report from primary care physician indicates “right” knee, H&P from surgeon indicates “left knee” but no one notices this discrepancy.


Patient taken to preoperative area. Nurse obtains routine information from patient and asks patient to state the surgery he is having. Patient says that he having a left knee arthroscopy. This is confirmed by the nurse by comparing what patient said to the procedure listed on the OR schedule, which is presumed to be correct. Nurse does not notice the inconsistencies in laterality that were present in the two H&Ps.


Covering anesthesiologist conducts pre-operative anesthesia assessment for CRNA scheduled to participate in the case. Anesthesiologist notes “knee arthroscopy” in record - does not indicate which knee. Anesthesiologist does not notice the inconsistent surgical site in the H&Ps.


Surgeon gets the patient’s consent for a right knee arthroscopy and marks the right knee as the correct surgery site. The circulating nurse witnesses the patient’s signature on the consent form. 

Room set up for procedure. CRNA reads pre-op anesthesia assessment done by covering anesthesiologist to determine what is needed for the procedure.


Patient enters the OR. Patient identification validated and this is documented on “time-out” form. Although right knee has markings indicating it is the surgery site, surgeon places the patient’s left knee in stirrup for prep. Circulating RN preps the left knee and surgeon drapes the left knee.


Circulating nurse verbally initiates time-out (e.g., confirms patient’s name and type of surgery, including the site) and receives verbal confirmation from technical staff; no verbal response from surgeon or CNRA. Nurse documents completion of all “time-out” steps.


Surgeon proceeds with arthroscopy, which is performed on the left knee.


Patient awakens from procedure and asks why his left knee is painful as he expected to have surgery on his right knee. Patient and family immediately made aware of the mistake.


Investigations following the event identified several contributing factors:


         Upon receipt of the OR reservation, the hospital faxed a copy of the surgery booking to the clinic. According to procedure, the clinic is to verify the information on the booking and fax back the verification to the hospital, however this did not happen.

         The patient’s history and physical (H&P) exam reports were not received by the hospital 72 hours prior to surgery (as required by procedure)

         During the preoperative assessment the anesthesiologist noticed that patient seemed to be “confused” about which knee was being operated on, but this observation was not documented in the anesthesiologist’s preoperative assessment notes nor was it communicated verbally to the surgeon.

         The orthopedist had talked to patient about having an arthroscopy on his left knee at some later date and this contributed to the patient’s confusion. 





AHS 450: Project 6

Student Name:


Suggested Risk Reduction Action

Reliability Science Tactic





























 The time line event is attcahed in the word doucment , it doesn,t shwo in here


Subject General
Due By (Pacific Time) 03/27/2013 10:46 pm
Report DMCA

Chat Now!

out of 1971 reviews

Chat Now!

out of 766 reviews

Chat Now!

out of 1164 reviews

Chat Now!

out of 721 reviews

Chat Now!

out of 1600 reviews

Chat Now!

out of 770 reviews

Chat Now!

out of 766 reviews

Chat Now!

out of 680 reviews
All Rights Reserved. Copyright by - Copyright Policy