Case Study Analysis

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Case Study Analysis

Medical errors that damage patients are a major healthcare issue. Justin, an 11-year-old
who died after an orthopedic treatment, and Josie King, an 18-month-old who died after burns,
will be examined in this study. These stories show how organizational structures, communication
breakdowns, and transparency and accountability affect medical blunders. We study these
examples to understand the systemic factors that cause such incidents and their effects on patient
safety.
Factual Analysis: Dale’s Case
An infected ankle required surgical drainage, killing Justin. However, medical blunders
during and after the treatment were fatal. Poor pre-operative procedures, including medical
assessment, lead to difficulties. Poor postoperative care worsened the condition. Lack of hospital
real-time communication was crucial to comprehending this situation. The lack of open
communication among medical professionals delayed surgery problem detection and
management. This caused hospital staff denial and defensiveness. Justin's family requested a full
autopsy after the partial autopsy failed to explain his death (Micalizzi, 2008). A hospital culture
of silence, motivated by fear and reluctance to accept wrongdoing, made information gathering
difficult. This highlighted healthcare organizations' need for transparency and reform (Vian,
2020).
Factual Analysis: Josie King`s Case
Her bathtub accident burns led to hospital-acquired septic shock, which killed Josie King.
Dehydration and a methadone overdose were initially blamed for her death, but a hospital-
acquired illness was found instead. Josie's tragedy was caused by poor communication and

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neglect of her needs. Her mother's water requests were ignored, causing serious problems. Josie's
death was complicated by root cause analysis's changing narratives. The King family persevered,
founding the Josie King Foundation and fighting for Johns Hopkins Hospital patient safety
measures (Nitkin & Broadhead, 2016). Their experience emphasizes patient advocacy and
healthcare system reform.
Organizational Structures
Both stories show how organizational structures and processes affect healthcare decision-
making. Organizational structures might impact decisions that seem appropriate within the
institution's culture and priorities but are wrong from a patient-centered perspective. Justin's
hospital's culture didn't encourage quality improvement or open communication after
unfavorable events. This neglect fostered a hospital staff culture of denial and defense,
hampering the family's truth-seeking. Priorities like risk management often trumped patient
safety and openness (de Bienassis et al., 2021). Organizational issues at the hospital were to
blame for Josie's tragedy. Communication breakdowns and failure to meet patient requirements
were systematic issues. The hospital's priorities and processes didn't support patient-centered
care and communication. Reluctance to disclose information and promote transparency was
crucial to organizational power. Both cases showed that hospitals' legal and risk management
concerns kept them quiet. These organizational structures hindered access to vital information
and understanding the patients' deaths.
Information Finding Challenges
Finding information on the patients' deaths was challenging in both circumstances. The
healthcare industry is sometimes opaque, and hospitals may not report medical errors. Justin's

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family had trouble getting complete death details. The initial partial autopsy was insufficient, and
the hospital's culture of secrecy hampered the family's investigation. Lack of candor delayed
their understanding of what happened. Like Josie, the fluctuating narratives in root cause studies
confused the family and made it hard to determine her death's cause. The varying results
complicated a terrible situation.
In conclusion, Dale Micalizzi and Josie King demonstrate the severe effects of medical
blunders and the need to address systemic issues in healthcare systems. Risk-focused
organizations and communication breakdowns can lead to disastrous judgments. The difficulty of
acquiring information emphasizes the need for healthcare transparency and accountability.
Healthcare companies must prioritize patient s