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Landmark studies To Err is Human (1999) and Crossing the Quality Chasm (2001) from the Institute of
Medicine (IOM) identified medical errors are causing harm and death to almost 45,000 Americans and
costing over $29 billion every year. Other studies have indicated preventable healthcare associated
conditions (HACs) such as infections, sepsis, CHF, and pneumonia are main contributors for increasing
the length of patient stays, the cost of care, and the likelihood of mortality (death).
Consider the below case study:
Margret Spinner-Ramirez is a 66 y/o female Hispanic-American who speaks both Spanish and English
fluently. She is retired, lives alone, and has Medicaid as her primary insurance. Ms. Spinner-Ramirez was
scratched by a stray cat that she feeds on her back porch daily. She has been cleaning the wound daily;
however, after 2 days she went to her local ER for increased pain, redness, and swelling in her left lower
leg wound where she was scratched by the stray cat. Ms. Spinner-Ramirez explained she recently had
her left knee replaced about 6 months ago and verbalized new difficulty with baring weight on that
extremity to the point that she was having to use her cane again. Her vital signs at the ER visit were stable.
Her left leg wound was cleaned and redressed. After 5 hours in the ER, Ms. Spinner-Ramirez was
discharged to home on oral Keflex for her left lower leg infection and was instructed to call her primary
care physician for a follow-up appointment. Five days later Ms. Spinner-Ramirez was taken back to the
same ER via ambulance. Her neighbor found her lethargic, short of breath, and was experiencing
difficulty being able to move. A CT scan and blood work revealed that Ms. Spinner-Ramirez’s knee
replacement in her left leg was infected secondary to the cat scratch. She was admitted as an inpatient
for sepsis. She needed to have a second left knee replacement surgery with wound irrigation and
debridement, which extended her inpatient stay to 3 weeks. Once she was discharged to home, she
required six weeks of IV antibiotics, extensive rehab, and home health.
If you were in charge of a healthcare insurance company:
Explain why insurance companies (which are considered payers) should or should not pay (reimburse) for
injuries, extended costs, readmissions, or death (mortality) from a hospital-acquired infection or medical
error. Support your why or why not?
Describe two ways (initiatives) healthcare quality can be improved to help reduce errors and improve
patient safety.
Discuss how creating incentives for providers (healthcare organizations) can improve quality and
reimbursements (payments) for services/care.
Resources:
Understanding Health Insurance
What’s Behind the Health Insurance Rankings
Hospitals will have to Pay for their Mistakes
Medical Errors: Focusing More on What and Why, Less on Who
National Business Coalition on Health: Health Care Purchaser Toolkit
Agency for Healthcare Research and Quality
Sample Solution
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