A patient at your hospital is sent to cardiology for a routine test. The patient

Question

A patient at your hospital is sent to cardiology for a routine test. The patient returns without incident, and you document the time and condition of the patient on return to the room. The next day, you are summoned to the unit manager's office, along with the charge nurse and unit secretary. The manager describes how the patient was given a dose of Glucophage the morning of the test. The physician wrote an order to hold the Glucophage for 2 days prior to the test because of contraindications between the medication and the intravenous contrast dye. The manager demands an explanation for the incident because controls are in place because of similar incidents on the unit that should flag the medication, requiring the nurse to hold the medication prior to the test.

A.   Who is responsible for initiating a root cause analysis (RCA)?

B. How would you conduct a root cause analysis to determine the cause of the problem? Who would you include? What is the purpose for conducting the RCA?

C. The hospital has a nonpunitive policy for mistakes and errors. How does this affect the RCA if the cause of the problem is identified as a mistake by the unit secretary?

D. The investigation reveals that there were 12 admits and discharges occurring around the time of the incident, with only one unit secretary. Of the admissions, 10 were attributed to the same physician who ordered the test. The nurse was admitting a complicated patient with multiple needs when the patient left for the procedure. Based on this information, where might the fault lie?

E. What possible suggestions could you make to decrease the possibility of a similar incident?

F.   How did the unit use failure mode and effects analysis?

G.  Which TJC patient safety goal was addressed in this case study?

H.   One of the process problems identified involved nurses transcribing the computer MAR onto a sheet of paper. The nurse then takes the handwritten paper into the medication dispensing room to remove medications. The computer on wheels is too large to take into the small medication room. What is this an example of?

Explanation / Answer

1-RCA expect that frameworks and occasions are interrelated. An activity in one territory triggers an activity in one more and again, et cetera. By following back these activities, you can find where the issue began and how it developed into the side effect you're presently confronting. RCA accept that frameworks and occasions are interrelated. An activity in one zone triggers an activity in one more and again, et cetera. By following back these activities, you can find where the issue began and how it developed into the side effect you're currently confronting. Examine a circumstance completely before you can continue forward to take a peek at factors that added to the issue. To boost the viability of your RCA, get together everybody – specialists and cutting edge staff – who comprehends the circumstance. Individuals who are most acquainted with the issue can help lead you to a superior comprehension of the issues.

2- A little, engaged group should lead the underlying driver investigation. Individuals ought to incorporate correspondence staff, wellbeing/social administration staff and, if accessible, examine staff. Ordinarily, a similar group leading the circumstance investigation will likewise direct the main driver examination. An underlying driver examination (or different types of issue investigation recorded in the asset area of this guide) ought to be directed as a feature of the circumstance examination. It can occur as a major aspect of a partner workshop or, if necessary, amid extra talks with partners or groups of onlookers. Recognize however many causal factors as might sensibly be predictable. Begin with the issue and conceptualize causal components for that issue by asking "Why?" The work area audit directed amid the circumstance examination and a partners' workshop are great spots to discover causal variables. Task staff can likewise ask themselves (in light of their own understanding) and partners "why" or "so what" inquiries to distinguish causal variables.

3-The potential effect of tending to the correspondence challenge. The more noteworthy the possible result, the more essential it is to address.

How troublesome it will be to contact the gathering of people related with the correspondence challenge.

The command appended to the subsidizing.

Different assets accessible to address the correspondence challenge. There might be different accomplices chipping away at that correspondence challenge or extra financing streams accessible.

Regardless of whether nearby is a legitimate request in which to address the correspondence challenges. It might bode well to address negative supplier states of mind before producing interest for supplier administrations.

In the event that in excess of one causal factor is connected to the main driver. At the point when a main driver is the wellspring of numerous causal components, it shows that tending to the underlying driver can have extensive impacts.

4-Particularly with regards to medical caretakers.. The overview likewise recognized an important business subject in medicinal services laborers going up in contradiction of additional duties over their consolation level. The supplier lack implies less staff individuals must gap a noteworthy outstanding task at hand, pushing a few representatives to the edge of fatigue and diminishing employment fulfillment significantly.

Related Questions

Navigate

• Browse (All)
• Browse A
• Subjects

Integrity-first tutoring: explanations and feedback only — we do not complete graded work. Learn more.