System- wide safety failure of Healthcare System

        The adverse event is related to the Libby Zion who was died within 24 hours after taken to the hospital emergency. She died because of the lack of attention given to her by the doctors of the healthcare system. Her temperature reached at 107 because of lack of attention and proper evaluation of the doctors as they did not diagnose the real problem and wrong medication resulted in the death of Libby.

        The nurses and other hospital staff including senior doctors are the people who got the impact of this case. The hospital was struck in trouble as Zion (Father of the victim) filed a case against the hospital and its staff.

        Systemic failure, in this case, is caused by doctors and other medical staff. In this case, there was no other error as lack of facilities in the hospital to rescue and save the life of the patient. in fact, the whole situation was created by the poor management of the hospital as the senior doctor did not take notice when Libby was suffering from fever and her fever temperature was continuously increased.

        Doctors handed over the case to the new and inexperienced doctor who was not enough capacity to diagnose the actual problem. And they were not able to advice proper treatment and required medications.

    Because of the adverse event of the Libby death changes were made in the healthcare center at the large scale. For instance changes in the night float system were made. Even the residents were allowed to sleep with patients for their care [1].

    New reforms were made for the doctors and medical staff to ensure patient’s safety. In accordance with reforms patients in the first crucial 24 to 36 hours is the responsibility of the senior doctors they cannot assign their case to the new and inexperienced doctors and medical staff.

References of Healthcare System