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Case Study example - Critical Incident Reporting

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Masters
Case Study
Health Sciences & Medicine
Pages 12 (3012 words)
A 55 yr old female was admitted to the ICU following a spontaneous subarachnoid haemorrhage which resulted in brain stem death. The patient's parents were also present in the hospital. Two sets of brain stem death tests had been carried out. News of brain stem death was communicated by a Jr…

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The process of withdrawal of ventilatory support was also explained to the parents. However they did not want the ventilatory support to be withdrawn till the patient's sister had arrived from Canada in 48 hrs. Despite further explanations regarding the concept of brain stem death, the family threatened legal action for withdrawal of ventilatory support . The following day a senior consultant and senior nurse in the ICU came into the unit and were informed of the situation and intervened. After lengthy discussions with the parents, ventilatory support was withdrawn. The heart stopped beating shortly after.
The reason for examining these features in the case study is to gain an insight into the errors in the system and clarify human error in the cause of such incidents. This is a key characteristic of critical incident reporting (Buckley, Short, Rowbottom & Oh, 1997). A review of these features helps in highlighting the problems and paves the way for quality assurance through implementation of preventative measures to control such incidents. By analysing these key features, the critical incident analysis assists in identifying areas of improvement within the ICU.
Brain stem death has been accepted as death of the individual in the United Kingdom since 1976, when the royal colleges published criteria for making a diagnosis of what was then called brain death (Royal Colleges, 1976). ...
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