Question

A 36-year-old patient with kidney failure comes to the hospital to have a special arteriovenous fistula placed in his left arm to allow him to begin dialysis in a few weeks. The surgical team is about to operate on the wrong arm but a junior member of the care team notices the mistake and speaks up. Which of the following actions is most likely to improve the hospitals safety system?

1) Engage in open conversation about what happened and why.
2) Enforce a brief leave of absence for the providers who were caught making a mistake.
3) Privately thank the caregiver who caught the mistake.
4) No action is needed because the patient was not harmed.

Answer 1

The most effective means to improve hospital safety after a near-miss would be an open discussion to understand the underlying cause and implement systemic changes.

Step-by-step explanation:

The most likely action to improve the hospital's safety system after the surgical team almost operated on the wrong arm would be to engage in open conversation about what happened and why. This proactive approach facilitates the analysis of the events that led to the near-miss and the implementation of steps to prevent similar incidents in the future. This might entail adopting or refining checklists, improving communication protocols, or increasing staff training, based on the principles established by Dr. Pronovost and Dr. Gawande. Enforcing a brief leave of absence does not address systemic issues, privately thanking the caregiver does not lead to systemic improvement, and taking no action ignores the potential for future harm.