Overview The final project for this course is an error analysis and recommendations paper. Students ...
Overview The final project for this course is an error analysis and recommendations paper. Students will review a case study that discusses a medical error leading to an adverse patient outcome in a hospital or other healthcare organization. Students will determine the type of error that occurred and its causal and contributing factors, and then recommend strategies that can be used to lower the incidence of the error. In this assignment, you will demonstrate your mastery of the following course outcomes: Recommend measurable evidence-based patient safety improvement strategies through analysis of factors leading to adverse patient outcomes Develop key elements of disclosure and incident reporting systems that address the needs of patients, families, and healthcare systems and are consistent with state and federal reporting requirements Analyze patient safety culture using appropriate assessment tools for recommending methods to effectively improve culture Propose essential communication and teamwork strategies that are measurable and promote safer patient care in healthcare organizations Prompt In your error analysis and recommendations paper you will answer the following question. What caused the medical error that occurred, and how would you suggest that the error could be prevented from happening again? To answer this guiding question, you will analyze the medical error in the case study you choose. (see attachment for selected case study) Specifically, the following critical elements must be addressed: Root Cause Analysis (RCA): In this section, you will provide an overview of the details in the provided case study that led to adverse patient outcomes. This overview will be in the form of a flowchart, which you will then use to help you analyze the medical error. Specifically, you should include the following: Timeline: Using a flowchart, summarize the events, processes, and staff involved in the timeline of events that led to the medical error. Factors: Based on your flowchart, use a modified root cause analysis to do the following: Identify two contributing factors that led to the medical error Identify one causal factor that led to the medical error Patient Safety Strategies: In this section, you will use the factors you identified to recommend a measurable evidence-based patient safety improvement strategy. Specifically, you should include the following: Recommendation: Based on the contributing factors or causal factor that you identified, recommend an evidence-based patient safety improvement strategy. What role would patients and families have in your recommendation? Measurement: How will the strategy be measured so that medical staff can determine whether the strategy led to improved patient safety? In other words, what will the primary measure be? What types of data should be collected? Disclosure: In this section, you will develop key elements of disclosure and incident reporting systems. Specifically, you should cover the following: Details: Based on state and federal reporting requirements and the results of the root cause analysis (RCA), identify the details that would be necessary to disclose the error to the patient and family. Method and Preparation: How would you suggest disclosing these details to the patient and family? What preparation would be needed for the staff, patient, and family before the disclosure? Reporting: What elements of the RCA and corrective action plan (strategies) would need to be shared with accrediting or regulatory agencies? For example, what elements should be reported to the State Department of Health and Human Services? What should be reported to The Joint Commission? Patient Safety Culture: In this section, you will analyze patient safety culture through the use of a survey as an assessment tool. Specifically, you should address the following: Analysis: Analyze all of the patient safety culture survey results at the facility where the error occurred. These results are in your Final Project Case Studies document. What does this survey tell you about the patient safety culture at the facility? Based on your analysis, what are the areas for improvement? Outcome: In what ways might the outcome have been different if the facility had a stronger patient safety culture? Your response should be based on your analysis of the patient safety culture survey. Recommendation: Recommend one method that could be used to improve the patient safety culture. Justify your recommendation with your analysis of the survey. Communication: In this section, you will propose communication and teamwork strategies, explaining how these strategies promote safer patient care. Specifically, you should address the following: Strategy: What strategy or strategies could be used to improve communication and team building? Explain why you selected the strategy or strategies, basing your response on your analysis of the medical error and the patient safety culture. Safer Patient Care: How does the strategy (or strategies) promote safer patient care? What evidence do you have to support your response? Measurement: How will the communication and teamwork strategy or strategies be measured? In other words, how will we know that communication improved? What to Submit Your error analysis and recommendations paper should be 10 to 12 pages in length (plus a cover page and references) and must be written in APA format. Use double spacing, 12-point Times New Roman font, and one-inch margins. All references and citations should be cited in APA format.
