CONTEXT: WINTER 2024 CASE STUDY ANALYSIS: INVESTIGATION AND REPORTING You are the risk manager in the healthcare setting where the sentinel event took place. The sentinel event was brought to your attention for investigation. INSTRUCTIONS: 1) Critically examine the case study with your team. 2) Use root cause analysis tools (your choice) and techniques to systematically investigate and analyze the root causes. 3) Answer the specific questions in the case study guide. Some of the questions at the end of the case study may be useful. 4) Use the following template to report your findings. REPORTING TEMPLATE: 1. Summary: Brief overview of the case, findings, and recommendations. 2. Introduction: Context and importance of the case. 3. Methodology: a) How did you conduct the investigation? b) What sources did you use for your investigation? 4. Findings: a) Refer to the list of questions in the case study guide; answer each of the questions; use the headings provided in the guide. b) Refer to the list of questions at the end of the case study and answer those aiuneHone nc uanll/n CASE STUDY GUIDE: ROUTINE ENDOSCOPIC PROCEDURE Based on the case study "A Routine Endoscopic Procedure," here are questions to guide your root cause analysis. 1. Risk Identification: What were the initial reasons for Dorothy Johnson's routine endoscopic procedure, and how did these reasons contribute to her subsequent health complications? Identify the critical points where communication failures occurred regarding Dorothy's care and condition. 2. Risk Assessment: • Assess the impact of procedural and diagnostic overuse on patient safety, particularly in the context of Dorothy's case. Evaluate the decision-making process behind performing the endoscopic procedure and the subsequent sphincterotomy, considering their necessity and potential risks. 3. Contributing Factors: Discuss the systemic failures that contributed to Dorothy's deteriorating condition post-procedure, including issues related to emergency room waiting times, follow-up care, and communication between healthcare professionals and the family. • Analyze the role of informed consent in Dorothy's case, particularly regarding her understanding of the procedure and its potential complications. 4. Technology and Equipment: If relevant, assess the impact of technology and equipment availability on the outcome of this case. 5. Leadership and Accountability: Discuss the role of leadership and accountability in managing such high-risk procedures. 6. Learning and Improvement: What lessons can be learned from this incident to improve future patient safety? 7. Ethical Implications: Explore the ethical implications of the error on patient and/or trust and care quality. 8. Policy Implications: What policy changes would you recommend for preventing such errors in the future? 9. Preventative Measures and Improvements: a) Based on the case, suggest strategies to improve the informed consent process, ensuring patients and their families fully understand the risks and benefits of medical procedures. b) How could healthcare systems improve communication and follow-up care post- procedure to prevent similar adverse outcomes in the future?/n

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