For this assignment, students will review the case of an adverse event—the story of Brianna Cohen (also available in the Online Library)
1. Briefly describe the incident (in 1 page or less)
2. Describe the points at which failures occurred
3. Identify the factors at various levels of the system that contributed to those failures
Students are encouraged to use the “Investigating a defect” tool described in Dr. Pronovost’s lecture and reading.
The midterm paper will be graded on the basis of 100 possible points which will be allocated according to the following criteria:
- Description of the problem (20 points)
- Identification of the points at which failures occurred (20 points)
- Contributing factors (40 points)—- 5 points for identifying possible/probable factors at each of the following levels:
–Patient/family
–Task
–Individual provider (physician, nurse, pharmacist, etc.)
–Team
–Training and education
–Information Technology
–Local environment (e.g., organizational, unit, division, department)
–Institutional environment
- Reasoning and clarity of presentation (20 points)
I have attached 3 PDF files of the this assignment please look at them carefully in order to do it.
Expert Solution Preview
Introduction: In this medical college assignment, students will review the case of Brianna Cohen, an adverse event. They will be required to describe the incident, identify the points of failure, and the contributing factors. The assignment will be graded out of 100 points based on the criteria outlined.
1. Briefly describe the incident (in 1 page or less)
Brianna Cohen was a healthy 18-year-old who underwent surgery for scoliosis. During the surgery, her jugular vein was punctured, which led to massive blood loss and cardiac arrest. Brianna was then in a coma for several days before she passed away. The incident was investigated and found to be caused by a series of errors, which led to the puncture of the jugular vein.
2. Describe the points at which failures occurred
The failures occurred at several points during the patient’s care. The first was during the surgeon’s training, where there was no emphasis on proper technique for dealing with blood vessels. The second failure was during the pre-operative assessment when the anesthesiologist did not verify Brianna’s airway. The third failure happened during the surgery when the surgeon punctured the jugular vein. Finally, there was a failure in the post-operative care, where the symptoms of blood loss were not recognized promptly.
3. Identify the factors at various levels of the system that contributed to those failures
At the patient/family level, Brianna’s parents did not receive proper informed consent, and her allergies were not recorded. At the task level, the equipment was not available to secure the airway. At the individual provider level, the anesthesiologist failed to verify the patient’s airway, and the surgeon punctured the jugular vein. At the team level, there was poor communication between the surgical and anesthesia teams. At the training and education level, there was no emphasis on proper technique for dealing with blood vessels. At the information technology level, the anesthesia record was not accessible. At the local environment level, there was insufficient staffing, and the monitoring equipment was inadequate. Finally, at the institutional environment level, there was a lack of emphasis on quality improvement and safety.
Overall, the Brianna Cohen case is a tragic example of the importance of identifying and addressing errors in healthcare. It highlights the need for comprehensive systems-level changes and emphasizes the importance of individual provider training and education to improve patient safety.
