Analysis of a Case from the “Real World”
Description
The assignment is worth 200 points or 20% of the overall course grade. The assignment is to analyze the case provided below by answering all the questions included in a scholar paper format.
This case: A patient on a medical unit received the wrong medication and was transferred to intensive care due to complications from the medication. Two days later the quality improvement department forms a team to complete root cause analysis on the error. The team is given information about the error and informed that the same error had occurred on two other units in the past year for a total of five times. The hospital is new to using root cause analysis. The team consists of a physician, a representative from medical records and one from informatics, two staff nurses (one from the unit where the error just occurred and one from one of the other units that experienced the same error), a member of the policy and procedure committee, a nursing student, and a medical student. There is a lively discussion and sharing of possible causes for the medication error. In the beginning, the team is told to not narrow their choices of causes and to focus on the system rather than assuming individual staff reasons for the errors. During their analysis, the team used a fishbone analysis chart and a Pareto chart. When the team completes its work it is informed that the patient has sued the hospital. The team is upset, but they listen to the risk management staff and attorney.
The analysis must respond to the following questions:
Who should be on this team and is not included? Why?
Why is root cause analysis important?
What questions should the team ask?
What are some types of causes the team might identify?
Why did the team use the fishbone analysis chart and the Pareto chart?
What is malpractice? How might risk management and the hospital’s legal team use root cause analysis?
This assignment focuses on:
CO2: Apply quality improvement processes and tools to measure, analyze and interpret health care data. (PO1, 4)
CO5: Create and implement an outcome-based performance management program. (PO3, 7)
Instructions
Analyze the case provided by responding to all the questions in a scholarly writing paper format.
The paper should be a minimum of 4 pages excluding title and references pages.
The student is to cover all the case analysis questions.
APA 6th edition format required.
Rules of grammar, spelling, word usage, and punctuation are consistent with formal written work with no exceptions.
Must be a Word document.
The student case analysis paper covers the following questions (each question worth 30 points): At least 3 scholarly references and citations and references consistent with correct format.
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