Analyzing the series of events that occurred, involving Karemore Best Essay

Analyzing the series of events that occurred, involving Karemore Best Health NHS Trust and St. Patchup Hospital NHS Trust - Essay Example It follows with a series of recommendations for change to avoid such mishap from recurring at the two hospitals. This would also serve as a reminder towards other health care institutions towards strict compliance of standard procedures, and a guide to prevent such accident to occur in their organization. As requested by the Chief Executives of both Karemore and St. Patchup Hospitals, the author of the present report is a Radiology Services Manager of a hospital outside Prosperham City. Summary The persons directly involved in the unfortunate circumstance are: (1) Mrs. Wanda Doff, the patient, (2) Di Gital, a radiographer employed at St. Patchup from an agency, (3) Karl Amity, a radiographer at Karemore who took the patient’s radiology exams, and (4) Dr. Penny Drops, anesthetist at Karemore involved in Mrs. Doff’s operation. Mrs. Doff died of respiratory and cardiac arrests in the middle of a hip replacement operation at Karemore Hospital. Due to complaints of right hip pain approximately 6 months before the operation, Mrs. Doff underwent a chest radiograph antero-posterior (AP) position at St. Patchup Hospital, which was conducted by Di Gital.... That same evening, Karl Amity once again conducted the examination but mixed up results of the said patient with another. Seeing that the results were normal, Dr. Drops agreed that Mrs. Doff could go into the theatre and proceeded with the operation. Complications aroused, however, leading the patient into respiratory and cardiac arrests where practitioners were not able to resuscitate her. Range of Incidences and Mistakes Upon investigating the incident, it can be traced that lapses started with the imaging departments of both Karemore and St. Patchup Hospitals. Initially looking at St. Patchup Hospital, the lack of supplies - in this case batteries for the hoist - triggered the sole personnel left in the room, Di Gital, to aid Mrs. Doff. This, however, is not an excuse since patient safety is always a priority, and Di Gital should have realized the risk placed upon the patient in the process of lifting her alone. Furthermore, several other lapses are perceived from Karemore Hospita l. Taking into consideration that Karl Amity has been a qualified radiographer for several years, it is expected that he knows how to conduct the procedures adequately and follow given protocols. However, the patient was exposed to excessive radiation dose because of Mr. Amity’s mistakes with centring and lateral hip projection. Dr. Drops also committed a mistake in the act of ordering another chest x-ray without reviewing the patient’s records which could have revealed all the previous examinations she has undergone. Additionally, Karl did not question the doctor’s order for another x-ray even in the knowledge that he has met the patient earlier that morning. To make matters worse, he interchanged the results of the patient with another woman’s, thereby giving wrong results