Read carefully please. Please use the attached pages to complete the assignment. Note: two assignments are due this week: the Root Cause Analysis Worksheet and the description of the stakeholders and resources for your quality improvement plan.
This assignment is related to previous orders Assignment Topic Selection and approval (order # 8454604), Describe the Organization(order# 8491548), and Root Cause Analysis (order# 8590168).
See link :
https://psnet.ahrq.gov/primer/root-cause-analysis
- Assignment: Project Part III – Describing the Stakeholders and Resources for the QI Plan(USLO 2 & 4)
- Consider the root cause analysis performed and the results identified.
- Please review the table below provided by the Agency for Healthcare Research and Quality (2019):
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Table 1. Factors That May Lead to Latent Errors |
|
|
Type of Factor |
Example |
|
Institutional/regulatory |
A patient on anticoagulants received an intramuscular pneumococcal vaccination, resulting in a hematoma and prolonged hospitalization. The hospital was under regulatory pressure to improve its pneumococcal vaccination rates. |
|
Organizational/management |
A nurse detected a medication error, but the physician discouraged her from reporting it. |
|
Work environment |
Lacking the appropriate equipment to perform hysteroscopy, operating room staff improvised using equipment from other sets. During the procedure, the patient suffered an air embolism. |
|
Team environment |
A surgeon completed an operation despite being informed by a nurse and the anesthesiologist that the suction catheter tip was missing. The tip was subsequently found inside the patient, requiring reoperation. |
|
Staffing |
An overworked nurse mistakenly administered insulin instead of an antinausea medication, resulting in a hypoglycemic coma. |
|
Task-related |
An intern incorrectly calculated the equivalent dose of long-acting MS Contin for a patient who had been receiving Vicodin. The patient experienced an opiate overdose and aspiration pneumonia, resulting in a prolonged ICU course. |
|
Patient characteristics |
The parents of a young boy misread the instructions on a bottle of acetaminophen, causing their child to experience liver damage. |
Agency for Healthcare Research and Quality (AHRQ). (2019). Root cause analysis. Retrieved from https://psnet.ahrq.gov/primer/root-cause-analysisLinks to an external site.
- In a 2-3-page paper, identify and describe the findings of the root cause analysis.
- Identify the stakeholders who would need to be involved in a quality improvement plan that would address the clinical event reviewed. Note: When referring to an organization, remove all identifiers.
- From the table, identify which type of factor contributed to the clinical event occurrence?
- What role would each stakeholder play in the implementation of the quality improvement plan?
- What types of resources will the stakeholders need for the implementation of the quality improvement process to be successful? (Briefly address each of the following aspects in your paper.)
- Human Capital – Staff
- Time and Tools:
- Education materials
- Assessment tools
- Technology and support
- Financial – Budget cost and allocation
- Stakeholder Consensus
- Format of the paper:
- Adhere to APA formatting for paper organization, citations, and references.
- Provide a title page.
- Please use at least one scholarly source that is less than five years old to support your work.