CASE STUDY- FINDINGS After discharge, patient wrote letter to hospital. Laparoscopic surgery turned into open surgery. Call bell was broken in night. Patient phoned to nursing station but no oneanswered. Certified nursing assistant (CNA) came. Call bell fixed, but electricity problem. Nurse asked patient to yell & left closing thedoor.
DATA WE COLLECTED People participated- director of nursing, Q.AManager, nurse. Event occurred in NIGHT. Service impacted- maintenance department,nursing department. Full services impacted- electrical dept. human factors were relevant to the event-ignorance equipment performance- because of call bellbroken, patient got dissatisfied with room.
controllable factors- if nurse can come on firstphone call, the outcome was little bit effected. Staff- staff is qualified but proper indications notgiven
Root Cause Analysis Fish bone diagram. Main causes-Policies & proceduresEquipments & resourcesPatient factorsWork environmentCommunicationTask factorTeam factor
Root cause The Q.A Manager did not defined thepolicies for night shift staff. Q.A Manager is the root cause of theproblem but at the same time we cannotdeny that Nursing director also did notdefined SOP’s for nurses.
RECOMMENDATIONS Proper policies and procedures should bedefined by the Q.A Manager and NursingDirector. Standard operating procedures are set for allstaff in the hospital. Training program for nurses. Maintenance staff should be in night pluselectrical backup. Periodic checkup of all equipments in hospital.