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    Astro Case Study

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    Astrodita Adya Seta
    The physician who performed the intubation should be offered support, and the error should be disclosed transparently. [1] The physician should be told about the autopsy results by hospital administrators, and offered training to prevent future errors. [2] Support could include legal aid and improved skills training. [3] The family should be informed openly about all medical details, treatments, and the discovered error, with an apology. [4] Preventable errors can be addressed through ongoing training, monitoring, and ensuring treatments follow approved safety procedures.

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    Astro Case Study

    Uploaded by

    Astrodita Adya Seta
    26 views3 pages
    The physician who performed the intubation should be offered support, and the error should be disclosed transparently. [1] The physician should be told about the autopsy results by hospital administrators, and offered training to prevent future errors. [2] Support could include legal aid and improved skills training. [3] The family should be informed openly about all medical details, treatments, and the discovered error, with an apology. [4] Preventable errors can be addressed through ongoing training, monitoring, and ensuring treatments follow approved safety procedures.

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    The physician who performed the intubation should be offered support, and the error should be disclosed transparently. [1] The physician should be told about the autopsy results by hospital administrators, and offered training to prevent future errors. [2] Support could include legal aid and improved skills training. [3] The family should be informed openly about all medical details, treatments, and the discovered error, with an apology. [4] Preventable errors can be addressed through ongoing training, monitoring, and ensuring treatments follow approved safety procedures.

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    © All Rights Reserved
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    26 views3 pages

    Astro Case Study

    Uploaded by

    Astrodita Adya Seta
    The physician who performed the intubation should be offered support, and the error should be disclosed transparently. [1] The physician should be told about the autopsy results by hospital administrators, and offered training to prevent future errors. [2] Support could include legal aid and improved skills training. [3] The family should be informed openly about all medical details, treatments, and the discovered error, with an apology. [4] Preventable errors can be addressed through ongoing training, monitoring, and ensuring treatments follow approved safety procedures.

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    of 3

    Case Study Assignment

    Name of Fellow : ASTRODITA ADYA SETA


    Name Of Case Study : Transparency, Accountability, Disclosure: A Case Study by Denice Klavano

    Please answer the following questions based on your reading of the case study.

    Questions

    Task 1: Physician

    1. What should the physician who did the intubation be told and by whom?

    The problem of the case is about transparency. The physician actually has served and done
    the treatment appropriately in accordance the patient needs. Although certain errors and failures
    happened. Indeed several medical treatment might be failed and causing a negative impact. Thus,
    entire physicians have to understand about transparency. Explanation to the patient or families
    regarding the patient's condition, treatment, and effects after treatment, becomes the necessity for
    health care provider. The physician shall clarify every treatment provided to patient either poor
    prognosis or good. Sometimes inform consent is needed before treatment. Improving
    communication skills is required to physician so that minimalizes the misunderstanding between
    physician, patient, or families. Failures might happen, but should be avoided as if physicians could
    explain properly, calmly, clearly, and accurately according to medical reasons. These are known as
    accountable and transparency.

    2. What supports could and should be offered to this physician?

    Well, basically as a physician, who has to provide compassionate, appropriate, and effective
    care to treat health problems of patients even in ED. Indeed there is no one physician doing warm
    to patient. Regardless of the case, a physician has been negligent in carrying out his duty to provide
    a good care. Errors in medical procedures may occur, but this can be minimized. There needs to be
    a mindset that is instilled in medical personnel. Treatments that has an aspect of patient safety and
    person-centered methods, might be applied in every section of health care provider such ED.
    Supporting system for that implementation is transparency between health provider and the
    patients as well as their families.
    3. Are there any other actions that should be taken?

    Physician should defend and argue in cases that occur. Autopsy results discovering that patient
    was intubated into his oesophagus. It might be an impact of the procedure about treating patient in a
    rush hour at emergency situation and condition, so that result an unintentional errors. It can be
    conveyed by the support of lawyers specializing in health law, because basically, the physician has
    carried out the procedure according to the competence and certificate obtained, so that it has
    administrative legality and legal under the law.

    Nevertheless, the case can be controlled. Besides, training and flying hours experience are
    needed, medicolegal and ethical clearance understanding are also required to have good competent
    skills and better abilities. Physicians work to maintain, promote, and restore health by studying,
    diagnosing, and treating injuries and diseases.

    Institution of health care providers may support. Skill management and mentoring should be
    done sustainably. Monitoring and evaluation to all aspects of health services are very important to be
    conducted to improve and standardize the quality of health treatments. It can reduce errors that have
    fatal consequences such like this case. Part to emphasize is management of medical personnel, so that
    provide good quality in health care workers who prioritize to the aspects such :

    a. Actively participate in person-centred patient care;


    b. Respect between healthcare providers;
    c. Good communication;
    d. Provide a safe environment and patient safety;
    e. Speak the true condition of patients as a professional health provider;
    f. Treat appropriate care transparently;
    g. Receive a complaint to make improvement;
    h. Keep learning and maintaining quality;
    i. Uphold the medical science accountably.
    Task 2: Family

    1. What should be disclosed to the family?


    The important of transparency is for getting good service of treatment. Families reserve to proper
    information about every treatments, diagnoses, medications, therapies, etc. Worthy communication will
    support to solve the case problem. It could be that an apology is necessary to patient’s families.
    Physician have to explain clearly about every medical related information. Considering to the patient’s
    rights.

    2. How should this be done and when?


    I think when the sincerity excist to each other so this problem will be solved.

    3. Who should disclose this information?


    We are as health care provider should disclose all informations. Entire cases which had happened
    in daily life everywhere, might be considered to be learned such as an good experience. Therefore, skill
    management and medicolegal comprehension are main concern.

    Task 3: Measures and Considerations

    1. If the autopsy results showed an error in intubation, but it was felt that Brad's injuries were not
    survivable, and therefore the misplacement of the tube would not have changed the outcome, would
    that change your answers to the above?

    No, I have answered by two points of view. So that wouldn’t change my answer. I am thinking that
    always 2 or more possibilities in every accident. We are talking about “misplacement of intubation
    tube” then induces to Brad’s death. Indeed, it will not change outcome, but the most important is
    “mistake”. Therefore, a mistake is a failure, especially when it is recorded in the autopsy records. Even
    though any mistake or not will not change the condition. But properly a must that the mistake should
    not have occurred.

    2. What would be some ways that we can address preventable errors in general in our hospitals and
    practice?

    Preventing several errors need to be realized associated to aspect of patient safety. Leading
    sustainable training is to be a major factor for reducing errors in the hospital. Entire medical treatments
    must be in accordance to the approved Standard Operational Procedur (SOP). Subsequently, mistakes,
    errors, or fault should not excist.

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