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Safety Event Investigation Tool and the Brianna Cohen Case The Johns Hopkins Ho

by | Nov 22, 2022 | Nursing

 

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Safety Event Investigation Tool and the Brianna Cohen Case
The Johns Hopkins Hospital is one of the top five hospitals in the country. Patients from all of the world travel to Baltimore, Maryland to be seen and treated by some of the smartest medical teams in the world. According to their website, “The Johns Hopkins Hospital is a world renowned leader in patient care, serving the greater Baltimore community and patients from all across the globe.”
But even at one of the best hospital systems in the country, they still ultimately took responsibility in the death of a pediatric cancer patient, who was under their care. Her name was Brianna Cohen, and she was only two years old at the time of her death.
The Safety Event Investigation Tool below is used in situations where a safety event has occurred and Risk Management teams need to investigate the problem. For your assignment this week, you will use the provided articles to investigate the Brianna Cohen Case.
Review the articles provided and complete the tool to the best of your ability.
JHM Reports Untimely Death of Child Cancer Patient – Press Release.
https://www.hopkinsmedicine.org/Press_releases/2003/12_19_03.html
Medical Error Kills Hopkins Cancer Patient.
https://www.baltimoresun.com/news/bs-xpm-2003-12-19-0312190182-story.html
Medical Error Kills Young Cancer Patient.
https://apnews.com/article/1b6ec1a2dd94ea1bf4f6a15bcebbdf21
_______________________________________________________________________________________________________________________________________________Safety Event Investigation Tool
Identify Opportunities for Improvement
Purpose: To be used after identification of a defect in the care process (anything you do not want to happen again)
Type of Safety Event (SELECT ONE):
A. Hospital-Acquired Infection
Significant Adverse Drug Event
Operational defect,
B. Faulty Equipment
Sentinel Event,
C. Patient Loss of Life
Sentinel Event,
D. Patient Loss of Limb
1. What happened? (5-10 sentences)
2. Why did it happen? Where did the system break-down to allow this event to occur? (5-10 sentences)
3. What will we do/have we done to reduce the probability of it happening again? (5-10 sentences)
4. How will we know if these changes have worked? (Must have three changes)
5. What can we do to reestablish trust in our abilities? How can we build trust back in our employees, our patients, and the public? (5-10 sentences)

 

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