In the past, medical error was a topic relatively overlooked by the mainstream media. Today, stories about medical accidents and mistakes are becoming far too frequent. In the following discussion, you are asked to find an actual case study of a medical error that has been reported in the media. The case study you select is used for further discussion and additional assignments throughout the course.

Please see the learning resources area for this week for an example of a case study. See pp. 388-390 of the: Chisholm & Croskerry article.

Note: You may NOT use this case as your example.

To prepare for this Discussion:

Review the Learning Resources, especially To Err is Human: Building a Safer Health System and the Crossing the Quality Chasm: A New Health System for the 21st Century.

Research the popular press, web resources, and/or Walden Library for a case study in which a patient was harmed by medical error.

When choosing a case study, make sure it is from a reputable source such as a major newspaper, magazine, broadcast outlet, peer-reviewed journal, etc. The following are some examples:

National Public Radio (NPR)


Public Broadcasting Service (PBS)

YouTube Channels:

Centers for Disease Control and Prevention (CDC)

Agency for Healthcare Research and Quality (AHRQ)

The Joint Commission

Healthcare for All (HCFA Quality)

Note: Please limit your use of YouTube to channels where reputable organizations have used YouTube to disseminate information. Several examples such as the CDC, The Joint Commission, AHRQ, or HCFA, (examples of which are listed immediately above) or those belonging to major newspapers, news magazines or broadcast news sources. Additional examples of case studies can be found in Optional Resources in Weeks 1 and 2.

Be sure that your case study (which can be an article or video) addresses at least one of the IOM six dimensions of U.S. health care needing improvement.

Post a brief summary of the patient harm case study you selected (provide the link). Your summary should include a description of the error. Then, apply the IOM six dimensions of U.S. health care needing improvement to the case and determine which correspond(s) to the case and how. Finally, analyze how the quality of patient care could have been improved or the medical error prevented.

Support your work with specific citations from this week’s Learning Resources and/or additional scholarly sources, as appropriate. Your citations must be in APA format. Refer to the Essential Guide to APA Style for Walden Students to ensure your in-text citations and reference list are correct.



Required Readings

Spath, P. (2013). Introduction to healthcare quality management. Chicago, IL: Health Administration Press.

Chapter 1, “Focus on Quality”

Chisholm, C. D. & Croskerry, P. (2004), A case study in medical error: The use of the portfolio entry. Academic Emergency Medicine, 11(4), 388-392.

Note:Please use this case study for an example of a case study. You may NOT use this case as your example.

Case Study in Medical Error: The Use of the Portfolio Entry by Chisholm, C.D. & Croskerry, P., in Academic Emergency Medicine, 11(4). Copyright 2004 byJohn Wiley & Sons Journals. Reprinted by permission of John Wiley & Sons-Journals via the Copyright Clearance Center.

Kohn, L. Corrigan, J., & Donaldson, M. (Eds.). (2000, February). To err is human: Building a safer health system. Washington, DC: National Academy Press.

Note: Retrieved from Walden Library databases.

• Read the “Executive Summary” (pp.1–17)

Institute of Medicine. (2001, July). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

Note: Retrieved from Walden Library databases.

• Read the “Executive Summary” (pp. 1–22)

Note: This reading selection was also included in an earlier course, HLTH 1005. However, it is important enough to be included in this course, as well, because of its relevance to health care quality.

WebM&M & PSNet editorial staff. (n.d.). AHRQ patient safety network glossary. Retrieved from

PSNet Glossary. AHRQ Patient Safety Network. Available at: Used with permission of AHRQ WebM&M/PSNet

Agency for Healthcare Research and Quality. (2009). Key themes and highlights from the National Healthcare Quality Report (AHRQ Publication No. 10-0003). In National Healthcare Quality Report. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from

National Healthcare Quality Report. (2009). Key Themes and Highlights From the National Healthcare Quality Report. In Agency For Healthcare Research and Quality. Retrieved March 9, 2011, from

Wachter, R. (2010). Patient safety at ten: Unmistakable progress, troubling gaps. Health Affairs, 29(1), 165–173.

Note: Retrieved from Walden Library databases.

Patient safety at ten: Unmistakable progress, troubling gaps. Health Affairs 29(1) by Robert M Wachter. Copyright 2010 by PROJECT HOPE/HEALTH AFFAIRS JOURNAL. Reprinted by permission of PROJECT HOPE/HEALTH AFFAIRS JOURNALvia the Copyright Clearance Center.

Required Media

Laureate Education, Inc. (Executive Producer). (2011). Good Samaritan Hospital organizational chart—Week 1: Introduction to quality and safety. Baltimore, MD: Author.

Good Samaritan Hospital in Baltimore, Maryland is a 300+ bed community hospital offering a wide range of medical and surgical services. To illustrate many of the health care quality and safety ideas being covered in this course, this interactive organizational chart has been created and can be found by clicking the image below. You should be familiar with it from previous courses.

The chart provides a visual model of the administrative structure for a representative health care organization. For most weeks of the course, the chart also provides brief video programs that include remarks about the week’s topics from several of the hospital’s key administrators. Detailed instructions are on the chart’s home page.

This week Patient Care Manager Nadja Muchow, Vice President of Operations T.J. Senker, and Vice President of Finance Deana Stout discuss how their individual roles in health care impact the quality and safety of patient care at Good Samaritan Hospital.

Good Samaritan Hospital’s Organizational Chart Description and Video Transcripts (zip file)

Optional Resources

The Joint Commission. (2011, January 18). Facts about patient safety. Retrieved from

The Joint Commission. (2011). 2011 National patient safety goals. Retrieved from

U.S. Pharmacopia. (2011). Healthcare quality and safety. Retrieved from

AHRQ Patient Safety Network: Patient Safety Primers

American Society for Quality (ASQ)

Health care For All

Institute of Medicine of the National Academies (IOM)

Institute for Healthcare Improvement (IHI)