For your final Portfolio Project, you will write a paper detailing a risk management plan based on the following case study scenario. Your goal is to identify areas of risk and healthcare/medical error, and to safeguard future patients from having their safety compromised in a manner similar to what occurred in this case study. Your risk management plan must include:

• A root-cause analysis
• At least three recommendation(s) for improvement
• Two recommendations for how this situation could be avoided
• Identification of all roles in your analysis
• Quality, risk, and performance improvement diagrams and charts to support your analysis (e.g., a fishbone or other visual form of root-cause analysis, Pareto chart, tables, etc.)
• Commentary that relates the case broadly to what you have learned throughout the course and describes the roles played by quality management and regulation to prevent unfortunate occurrences such as the case described

Your paper should meet the following requirements:

• Be 10-12 pages in length, not including the cover or reference pages.
• Be formatted according to the CSU-Global Guide to Writing and APA Requirements.
• Provide support for your statements with in-text citations from a minimum of eight (8) scholarly references—four (4) of these references must be from outside sources and four (4) may be from course readings, lectures, and textbooks. The CSU-Global Library is a good place to find these references.
• Utilize headings to organize the content in your work.

The case is as follows:

You are the Chief Risk Management Officer for a large metropolitan not-for-profit teaching hospital. You have been assigned this case by the Chief Executive Officer due to the potentially sensitive nature of the situation and the CEO’s personal interest in disadvantaged and ethnic minority population groups. Your goal is to do a thorough risk analysis and create a risk-management plan as part of the overall quality management program for this facility based on the following case scenario.

A female patient, age 25 years, presents in the emergency room with pain in the right side of her lower abdomen. Her last name is Jonesky. She has been ill and vomiting for two days. The patient is triaged and asked to take a seat in the emergency room waiting area until she can be seen. Additionally, the patient speaks only Russian, and her husband, who is the only family member with her, speaks limited English, with Russian being his primary language.

Several hours have passed and the patient is still sitting in the emergency room, in extreme pain. The husband approaches the emergency room desk to try to communicate that his wife is worsening and in extreme pain. After several minutes of discourse, the patient is taken back into an examination room to be seen.

She is diagnosed with appendicitis and requires removal of her appendix. She is sent to a holding area outside of the operating room where she will wait to be taken into surgery. Upon her arrival, a nurse asks her name and due to the fact that the patient only speaks Russian, her name, “Jonesky” sounds very much like “Jones” to the nurse. Then anesthesiologist arrives and interviews the patient. Simultaneously, another emergency patient is brought into the holding area of the operating room. Her name is Samantha Jones. Samantha has fallen down icy steps and has broken her left ankle, which now needs to be repaired. This is a very busy night for the operating room. Additional staff members, who have already worked a full eight-hour shift, are called in to attend to this second case.

Both patients are interviewed and taken into ORs for their procedures. Since it is late, both surgeons do the required time-out procedure, but not as judiciously as they would have during the day. Staff members in attendance for both cases implicitly go along with their surgeon’s order and surgery following a time-out procedure that was not complete. As the first surgical procedure begins, the surgeon makes an incision into Mrs. Jonesky’s ankle and there is no sign of any broken bone. He realizes there is a problem. Additionally, in the second OR, the surgeon operating on Samantha Jones makes an incision and finds no sign of appendicitis. Both surgeons operated on wrong sites due to incorrect identification of the patient.

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