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Attention GreatContentCreator Overview: Safety and Quality; Patient Safety Indicators and Root Cause Analysis In this module we will look at how analyzing medical errors can impact the quality and safety of patient care through policy changes. Root cause analysis focuses on having a questioning attitude and looking deep into issues to identify the probable cause or causes of an error.

Date Posted: 30/01/2018
Category: Health Care
Due Date: 03/02/2018
Instruction
Assignment: Case Study/ Root Cause Analysis Students will read a presented case study. Utilizing the fishbone diagram method and ‘5 why’ method, complete a root cause analysis. CASE STUDY The patient is an 85-year-old patient with early onset dementia, who was admitted because of a transient ischemic attack (TIA). She ambulated without difficulty and had not shown any residual effects from the TIA. She was admitted for observation and diagnostic testing. She got up to use the bathroom. Since it was 2 a.m. apparently all the lights were out in the room. She tripped over a wheelchair that had been used earlier in the day to take her to interventional radiology. • Using the “5 Whys” method and fishbone diagram provided, • Identify the problem statement and the causes that you identify. • What contributory causes did you identify? • Discuss one of the likely causes and a possible impactful intervention. • If you needed to do an in-service to the staff to bring attention to the problem, what data and information would you use and how would you display that information? • Does your intervention address a short-term goal or a long-term goal? • Explain why you chose to address the goal • How would you follow up to be sure you addressed the root of the problem successfully? Article: Williams, P. M. (2001). Techniques for root cause analysis. Proceedings (Baylor University. Medical Center), 14(2), 154–157. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1292997/ ( ****Everything highlighted in grey I wrote. (In the attached document)
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