Reference no: EM133880576

Question

This case study takes place in a family practice clinic that is part of a critical access hospital in a rural setting. In this type of setting, the family practice clinic is often located in the same building as the emergency room and inpatient areas. Within the family practice clinic there are two full-time APRN and two physicians (one is full-time, and one works 3 days per week). One of the APRNs is fairly new to the clinic having graduated from a DNP Program six months previously. Marjorie Simpson is a DNP-prepared family nurse practitioner and a senior member of the team, having been employed in the setting for over 10 years. She and the physicians are currently mentoring the new APRN. The clinic has one medical assistant for each provider. Each primary care provider spends at least one day per week in the emergency department. On a typical clinic day in the primary care clinic, each provider is booked with 20 to 25 patients per day. While working in the clinic, the providers see a combination of standard primary care appointments as well as same-day/episodic type visits and considers the workload to be busy but manageable most days. Scenario A 38-year-old obese woman with remote history of asthma, and on oral contraceptives, presented to the family practice clinic with a 3-day complaint of right thigh pain, swelling, and red streaking on her skin. She had recently returned from a road trip to visit her sister in a neighboring state. The medical assistant obtained the patient's chief complaint and vital signs, which were within normal limits.

During that visit, the patient was able to see her primary care provider, Marjorie Simpson. On physical exam, the patient's right inguinal lymph nodes were enlarged. The primary care provider prescribed antibiotics and suggested the patient contact the clinic if her symptoms did not improve. Three days later, the patient called the clinic with complaint of new onset shortness of breath, chest pain, and rapid heart rate. The patient was seen by Marjorie Simpson in the clinic the same afternoon. The patient's blood pressure was within normal limits, however, her heart rate was 120 beats per minute. She had diminished breath sounds. The primary care provider thought the patient was having an asthma flare and advised her to continue antibiotics and asthma medications. Later that evening, emergency personnel were called to the patient's home after she fell. She was brought to the emergency department where she quickly decompensated and died. Autopsy revealed a large pulmonary thromboembolism.

Marjorie Simpson is a doctoral-prepared family nurse practitioner and a primary care provider employed by a critical access hospital in a rural setting. She works predominantly in the family practice clinic located in the hospital. As a result of the diagnostic error, Dr. Simpson has become a champion in the prevention of the diagnostic errors. Her search of the healthcare literature has helped her understand that errors in diagnosis are common and that many of them occur in ambulatory care settings. She spoke with the other primary care providers at the clinic. Each of them recalled cases in which an incorrect diagnosis was made, which resulted in a delay in effective treatment. All four providers were interested in doing something to prevent diagnostic errors in the future. They decide to initiate a quality improvement project to prevent these types of errors. Address the following in your analysis of the case.

1. Marjorie. Simpson and the other primary care providers in the clinic have decided on a team approach to address the problem. Who should be invited to participate as members of the team? Explain your answer.

2. Once the team is assembled, they set out to clearly and succinctly identify the problem they plan to address. Rather than focus on any one case, they decide to address the problem as it plays out over and over again in the clinic. What would you suggest as a clear and succinct problem statement?

3. Which quality improvement or patient safety tools would you recommend the team use early in the process to meet the following objectives:

a. to better understand the many factors contributing to the problem in their clinic, and

b. to identify root causes of the problem in their clinic.

4. Once the team has identified factors that contribute to the problem and root causes, they decided to implement the two strategies contained within the Toolkit for Engaging Patients to Improve Diagnostic Safety developed by the Agency for Healthcare Research and Quality. Describe the two strategies contained within the Toolkit.

5. Rather than implement both strategies all at once across all four providers, they decide to start small, trialing the strategies with one of the providers. Marjorie Simpson volunteered to be the first to trial one or more strategies. The team decides to use the Institute for Healthcare Improvement's Model for Improvement. This model requires the team to answer three questions before they implement the Plan Do Study Act (PDSA) cycles to test the effects of changes they plan to implement in the clinic. • Describe how they should proceed in answering the three questions.

- Describe how they should proceed in the first PDSA cycle with Simpson's patients. Include a description of each phase and the detailed activities that could be included in each phase.

- Incorporate the tools, worksheets, and other helpful information provided within the AHRQ Toolkit for Engaging Patients to Improve Diagnostic Safety.

6. Assuming that the first cycle went well, develop plans for the second cycle. Assuming it went well, develop plans for the third cycle.