Posted: February 15th, 2022

American Society for Health Care Risk Management


            There are three types of patient safety events defined under the Patient Safety Quality Improvement Act: adverse events, near misses, and errors. The discussion below will focus on medical errors as one of the types of patient safety events. According to Burke, J., C., and Green, 2019, medical mistakes that can threaten a patient’s life are deemed to occur in a healthcare system. In the United States, reports indicate that medical errors are one of the leading causes of patient deaths in health facilities. Medical errors occur due to misdiagnosis, technological problems, incompetence by healthcare workers, or work pressure due to a shortage of health personnel. According to the American Society for Risk Control of Health Care, 2019, misdiagnosis as a type of patient safety event occurs mainly in health facilities.

Summary of a patient safety event

           An example of a patient safety event was when a particular patient was misdiagnosed with cancer while suffering from tuberculosis. The patient had a prolonged cough and lightheadedness when she visited the health facility. The doctor who attended her insisted that there was no need to undergo TB testing since she exhibited cancer symptoms. According to her health records report, she lost appetite and had a prolonged cough. Another doctor on duty on a different day later found out that the patient had some alteration in the mouth. In this event, the doctor who assumed what the patient was suffering was directly liable since he exhibited incompetence.

Stakeholders involved

           In this particular patient safety event, the stakeholders involved were the health facility and the doctor that attended the patient. The health facility failed to have policies that guide physicians on the code of conduct regarding medical examinations. The health facility should have mechanisms of employing competent health workers and techniques of monitoring them when they are on duty. The doctor should have ordered a medical test to ascertain the patient’s suffering instead of making assumptions. Ignorance and incompetence made the doctor misdiagnose the patient, which is very detrimental to the patient’s health. 

A specific plan for prevention

            Conducting medical examinations and tests can aid in preventing misdiagnosis. A medical test would have prevented the misdiagnosis from the above case since the doctor would have known what the patient was ailing from based on the test results. According to Topcu et al., 2017, physicians are required not to make assumptions regarding the medical condition of any patient to avoid misdiagnosis at all costs. Different health conditions sometimes exhibit the same symptoms, so it is incumbent upon any physician to always request a medical test before starting any medical procedure on a patient. 

             Healthcare facilities should establish clear structures and guidelines on how physicians should carry out medical procedures. There should be mechanisms to monitor physicians on their conduct and handle such medical mistakes when they happen. That would help physicians to uphold competency and efficiency in their work. The administration should be ready and alert to investigate and address such issues accordingly. Policies and guidelines that stipulate what would happen to a physician in case of incompetency that may harm the patient would help curb such patient safety events. Also, the Human resource department should be very keen on what kind of health workers should be employed. A health facility should employ top-notch physicians with no criminal records and possess competent character traits.


           Hello, hope this mail finds you well. The administration wishes to share a prevention plan established recently to assist in executing and providing quality care regarding patient safety in our facility. Below kindly find the full details of the plan.

           All physicians will be required to use the available medical monitoring technology provided by the facility to verify and ascertain that they are following the appropriate medical procedure for the right patient. Monitoring technology will help the nurses pay more attention to the patient’s needs. Monitoring technology like the bed alarms and barcode system will help nurses know which patient needs immediate attention and verify patient medication. The head of the nurses unit should ensure that this plan is adhered to every time and that all systems are functioning every time.

           Before any patient is discharged from the facility, the doctor on duty should ensure that the patient understands and has complete knowledge of the recovery process, prescription, and home-based care. The doctor should make a report on the understanding of the patient and file it in that patient’s medical records file.

           All surgical teams are always required to verify all medical procedures stipulated in the universal protocol before starting a surgical process on a patient and sign the verification forms provided by the facility to prove that they have verified the medical procedure needed. That is meant to avoid any errors in the surgical process. The head of the surgical team should supervise this process closely.

            Last but not least, all health workers are required to embrace a team in their line of duty. All are needed to complement the other and cooperate to achieve patient safety. Teamwork is critical in achieving patient safety since it creates a good working environment. All heads of every unit should ensure and promote teamwork among their juniors.

           The above plan is essential, and everyone should strictly adhere to it to achieve patient safety at all times.

Thank you.

















American Society for Health Care Risk Management. (2019). Different roles, same goal: Risk and quality management partnering for patient safety

Burke, J. & Green, C. (2016). Risk management 101 for healthcare providers.

Topcu et al. (2017). Physicians’ and nurses’ medical errors associated with communication failures. J Pak Med Assoc67(4).




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