Q: How might these policies have been applied to our case?
A:
In this particular case, a system-based approach to care might have anticipated and prevented this error through the following steps:
Create specific written instructions for office procedures
Have the written procedures handy and easily available for staff to reference, if needed, before performing the task
Make sure during new staff orientation that personnel are trained and documented as proficient in each procedure
Have regular updates or ”recertification,” particularly for procedures that are done infrequently
A well-informed patient is often the first protection against mishaps. A patient education sheet given to the patient when the TST test was administered—describing the test, how it is interpreted, and implications of a “positive” test result—may have alerted the patient in the first place that her test had been misread
Create documentation forms that have built in “decision support”—for instance, instead of having a blank that says: “TST_____,” the form instead could describe: “TST: date applied, date read, mm of induration measured in 2 dimensions.”
