1-3 case study: single-event analysis—the wrong patient

Review the case study in Chapter 5.

After the initial patient misidentification, what systemic reasons can you identify that lead to subsequent caregivers not recognizing that the patient transferred to, prepped for, and undergoing surgery was not the right patient? Use the three components of root cause analysis to evaluate the following.

  • How significant was the role of data collection and data analysis in measuring the chronology of events? Explain.
  • From your perspective, what steps should have been taken to avoid this latent medical error?
  • Evaluate why and how humans produce errors and what precautions should have been taken in this case study.

For additional details, please refer to the Module One Case Study Guidelines and Rubric document.

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