Running Head: ADVANCE HEALTHCARE LEADERSHIP 1

WIL PROJECT

Name (Student ID)

Lambton College

CPL-5559-AHCT-0011-V2

Advance HealthCare Leadership

Instructor Name

Date of Submission

Word Count
ADVANCE HEALTHCARE LEADERSHIP 2

WIL Project

Introduction

Rudolf Virchow has described the term the pathophysiology of venous thrombosis,

which is also known as the Virchow’s triad, which includes three conditions for this illness to

occur, i.e. Motionlessness, injury in the endothelial layer, and hypercoagulability(inherited or

acquired molecular defects). Venous thrombosis can be of two types, superficial venous

thrombosis, or deep venous thrombosis (DVT). Many risk factors associated with both

inherited and acquired DVT have been studied to improve the approach towards a diagnosis

to prevent thrombotic events.

There are several standard preventive strategies and measures used by medical

officials such that using pneumatic devices and prophylactic anticoagulation, and strategies as

per the diagnosis of the fundamental risk factors in an individual patient. In this report, a

study of a hypothetical situation is done, where the topic covers the possibility of the risk of

having acquired DVT due to a careless approach by hospital staff. (McLendon et al., 2021)
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1. If Xu had not asked about the omission and the patient developed a DVT, whose fault

would it have been? Is it a human error or system error? Explain.

Ans. In this context, the description of one of the most common yet very critical surgery is

discussed, where a critical blunder is supposed to happen. The surgery that was taking place

was hip surgery for a fracture, which was very critical hence the follow up of the correct

protocol and managing the system was very important. This situation was saved by the

vigilant approach of Xu, he spoke about the error that happened in the order list given by Dr.

B. to be followed before and after surgery.

But let’s say, If Xu had not asked about the omission of Warfarin and the patient

developed a DVT, it would have been the fault of every person as well as system related to

the event, from the one who did not pay attention while making an order and omitted

Warfarin from the list to the one who noticed it late yet didn’t acknowledge it as a mistake

and waited long for addressing it. Also if Xu had ignored or missed the same, it would have

been a failure of the total system. First, let’s understand why is Warfarin inclusion in the

order list was so important. In orthopaedic injuries, hip fractures are very common especially

among elderly people, study shows that most of them have multiple co-morbidities as well as

they are most likely to be taking some form of anticoagulant at this age (Yassa et al., 2017).

When hip surgery takes place, it is very important to manage coagulopathy well

during overall treatment to reduce morbidity and mortality rate. Since hip surgery is one of

the major orthopedic bony surgery hence it is associated with a very high risk of bleeding

because of the breaching of multiple soft-tissue layers during the surgery and also bleeding

from displaced fractures. Hence it is very important to manage the warfarin use before most

orthopedic interventions. If not managed well it can cause the risk of postoperative bleeding

as well as a risk of thromboembolism in the patient which can lead to mortality (Yassa et al.,

2017).
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So as per the reasoning and after studying the consequences of omitting Warfarin

from the list of orders before such important surgery, seems critical and can’t be considered

as a general mistake. In this context, both Dr.B and Sophie would have been responsible for

the patient getting the DVT as well as Xu for not being vigilant. The doctor was an

experienced one who had handled many such cases in the past and has aware of how

important it is to follow the correct protocol set by the medical department before doing such

critical surgery.

First of all, if he was not feeling well, he wouldn’t have made that order list for the

patient to follow before, during, and after the surgery. Even if he did, he should have been

more aware of the safety culture, protocols of medicines, and system of the hospital the safety

to its patients. When he was aware that he wasn’t feeling well then he would have rechecked

the order list before handing it over to the nurse. The first mistake was avoiding his health

condition and not considering the rechecking of the order list created by him, assuming

mistake. This shows the overconfidence of the doctor about his actions. He ignored the

system and protocol because of his hurry, health issue, and overconfidence.

It was first the doctor’s responsibility to not miss such an important protocol of

medical science which can lead to a risk of thromboembolism as well as can cause issues like

serious bleeding during and after surgery. In, both situations in the worst cases can result in

death. So for such a serious case and condition, the doctor must have not missed it at any

cost. If we talk about Sophie, then she also had this overconfident point of view that the

doctor is experienced and cannot make mistakes, leading to ignoring the system and duty of

her to check the orders and get to know about it as soon as she receives it. She ignored the

safety policy and system of the hospital, her duty was to check the order list as soon as she

got it, and it took more than 2 hours for her to recognize the mistake. So this act of her

became the reason for the failure of the system.

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No matter how experienced and expert the doctor is, it was her duty to check the order

list and inform the doctor about the omission of warfarin then and there, or at least when she

realized it. Even after getting to know the mistake, she didn’t contact the doctor to clarify for

some personal reasons, which is again a failure in the medical system, especially when

dealing with such a serious case. She should have contacted the doctor immediately to clarify

the mistake and made the necessary changes, she shouldn’t have waited for so long to speak

to a doctor and ultimately forgotten it. If even Xu had not paid attention to the mistake and

reminded Sophie about the same, it could have led to a blunder that could cost the life of the

patient, hence would have put him also in mistake as. After going through the whole scenario

as well as a situation where the issue could have been worst, it shows that it could have been

the failure of the system due to human error, since the system is clear about to do tasks

before, during, and after such surgery, yet due to ignorance and errors made by human shows

that the main cause for this situation could have been a human error.

2. If Dr. B. had previously rebuffed Sophie for asking him questions about omissions in

orders, might that have prevented her from calling him? If yes, explain.

Ans. To run a successful and safe organization, especially in the health care industry, there is

a system that they are supposed to follow. Organizations like hospitals that deal with the lives

of people and are responsible for the safety of their patients must have a good safety culture.

The reputation of any hospital is based on how do they follow safety culture and how

integrated is the organisation. In the organization, all the members working including doctors,

nurses, and other staff members must have the authority to ask and point out questions in case

of confusion. No one is allowed to breach this protocol no matter what post he belongs to and

how experienced that person is (PSNet, 2019).

If Dr. B had previously rebuffed Sophie for asking him questions about the omission

in orders, then it breached the fundamental protocol of the system, Sophie must have not
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allowed such behavior in the first place and reported the restriction to the management. If this

was the case still it wouldn’t have prevented her from calling him. Even if she thinks that the

doctor is experienced, had been in the system for long, never made errors in the past while

making the list of orders, and had been dealing with such cases for years, still, she should

follow the duty of rechecking the list, and have any doubt then clear it then and there or on

call.

Though Sophie trusted the qualification and knowledge of Dr. B and found logic in

the omissions made in orders still it cannot prevent her from following the system. Though

she believed in the actions of a doctor so much, she had restrictions but in this kind of event

and critical scenario, she shouldn’t have thought about the restriction made by the doctor and

should ask questions regarding the order list regarding omissions made in orders. Hence, in

this situation, she would have questioned or doubted the list made by him and would have

called him to clear the reason for the omission of warfarin from the list even after having the

idea about how important it is during such critical surgeries.

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References

Agency for healthcare research and quality. (2019, September 7). Culture of Safety. PSNet.

https://psnet.ahrq.gov/primer/culture-safety

McLendon, K., Goyal, A., Bansal, P., & Attia, M. (2021). Deep Venous Thrombosis Risk

Factors. Treasure Island (FL): StatPearls Publishing.

Yassa, R., Khalfaoui, Y. M., Hujazi, I., Sevenoaks, H., & Dunkow, P. (2017). Management of

anticoagulation in hip fractures. EFORT Open Rev., 2(9), 394–402.

https://dx.doi.org/10.1302%2F2058-5241.2.160083