Frances Ballentine, RN, MSN, VP for Nursing Services, has a problem. A recent Jo

Question

Frances Ballentine, RN, MSN, VP for Nursing Services, has a problem. A recent Joint Commission inspection found several deficiencies at her hospital, including incomplete reporting of medication errors. The CEO gave her six months to fix this situation. Frances, who had been on the job for less than a year, already knew that the reporting of medication errors was problematic. She often found it difficult to complete her own monthly report on the number and causes of medication errors. She did not receive timely incident reports from every department, and many times these reports were incomplete. She also suspected that some incidents were going unreported. In her investigation, Frances learned that although there was a clearly defined process (Figure 17-8) in the procedure manuals that each floor used, the process seemed to be inconsistently applied when a medication error occurred. She also knew that there were some other issues but could not pin them down without some additional investigation. From her observations, she estimated that 20–30% of medication error incident reports were not completed correctly, not completed on a timely basis, or not completed at all. The next step of her investigation was to discuss the situation with the director of quality improvement (QI), Ally Ray. Together they agreed it would be worth creating a QI team to study the current work process of “reporting medication errors.” The discussion ended with Ally asking Frances to put together the necessary information to present to the hospital’s quality council for approval of the QI project. In the next quality council meeting, the Medication Errors Quality Improvement (MEQI) project was approved. The initial meeting of the MEQI project team consisted of representatives from the pharmacy and the six hospital units (north, south, east, west, northeast, southeast) who were knowledgeable about the reporting of medication errors. The meeting was devoted to training on basic TQM/CQI principles and tools. The group decided to use the FOCUS-PDCA framework as their guide for completing the MEQI project. The group had clearly completed the first two steps: F (Find a process to improve) and O (Organize a team that knows the process).

IN A 4 PAGE TYPED DOUBLE SPACED WRITTEN REPORT:

REVIEW THE CASE STUDY AND ANSWER THE FOLLOWING QUESTIONS: 1. Identify the problem or problems--what were they be specific? 2. Who did the CEO assign to "fix" the problem? 3. What did that person discover? 4. What process was used to investigate and correct the problem?   5. Was the problem corrected immediately? If not why not? 6. If you were advising Ms. Ballentine describe two or three solutions you would suggest she implement to correct the problem. 7. Was there a motivational problem? If yes describe 8. Was there a leadership problem? If yes describe.

Explanation / Answer

1.The problem in the case is incomplete documentation and improper leadership of Frances Ballentine where she is unable to command the subordinates and ask them to complete the records of medical errors.

2.CEO assigned Ms.Frances Ballentine to fix the problem.

3. Ms. Frances Ballentine discovered that there is improper documentation and the incomplete reporting of medical errors.

4. The process was studied thoroughly to investigate and then the problem comes to their notice. Frances Ballentine in association with the director of Quality Improvement, Ms.Ally Ray found a process to improve and formed a team that knows the process.

5. The problem was not corrected immediately but a team was formed to work on the improvement of the process.

6. In order to correct the problem, all the staff members hsould be instructed to complete the records of medical errors completely and not to leave any case of medical error unnoticed. A tem should be formed to monitor the reporting of medical errors religiously and to work on the same.

7. There was a motivational problem as the staff was not motivated enough to perform their duties religiously as there was no rewards and recognition to perform the duties properly.

8. There was a leadership problem as Frances Ballentine was not able to command the staff to report the medical errors peoperly and to keep the entire documentation complete.

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