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IHP 315 Milestone One Guidelines and Rubric For your first step in developing your error analysis and recommendations paper, you will select one of the case studies from the Final Project Case Studies document to be the focus of your entire project. You will then complete a root cause analysi s and recommend appropriate patient safety strategies. Remember, this is your first draft. You will have an opportunity to incorporate suggestions from your instructor and course content in later modules prior to submitt ing your final version in Module Sev en. In this first milestone, the following critical elements must be addressed: I. 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 t he following: A. Timeline: Using a flowchart, summarize the events, processes, and staff involved in the timeline of events that led to the medical error. B. Factors: Based on your flowchart, use a modified root cause analysis to do the following: i. Identify two contributing factors that led to the medical error ii. Identify one causal factor that led to the medical error Hint: For help with the RCA, refer back to your work relating to the AHRQ website in Module One. II. 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: A. 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? B. 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? Guidelines for Submission: Submit an APA referenced and formatted paper that is 3 to 4 pages in length, excluding the cover page and reference list. This will be a Microsoft Word document with double spacing, 12 point Times New Roman font, and one -inch margins. Rubric Critical Elements Proficient (100%) Needs Improvement (70%) Not Evident (0%) Value Root Cause Analysis: Timeline Using a flowchart, summarizes events, processes, and staff involved in timeline of events that led to medical error, with few gaps in the details Summarizes events, processes, and staff involved in timeline of events that led to medical error but without using a flowchart or with gaps in detail Does not summarize events, processes, and staff involved in timeline of events that led to medical error 25 Root Cause Analysis: Factors Based on flowchart, identifies at least two contributing factors and one causal factor that led to the medical error, using a modified ro ot cause analysis Identifies two contributing factors and one causal factor that led to the medical error but not based on flowchart, without using a modified root cause analysis, or with gaps in accuracy or logic Does not identify two contributing factors and one causal factor that led to the medical error 25 Patient Safety Strategies: Recommendation Recommends an appropriate evidence – based patient safety improvement strategy based on the identified factors and describes role of patients and families in recommendation Recommends a patient safety improvement strategy and describes role of patients and families in recommendation but strategy is not appropriate based on the identified factors or response has gaps in detail Does not recommend a patient safety improvement strategy 20 Patient Safety Strategies: Measurement Explains how the strategy will be measured so that medical staff can determine whether the strategy led to improved patient safety Explains how the strategy will be measured so that medical staff can determine whether the strategy led to improved patient safety, but with gaps in clarity or detail Does not explain how the strategy will be measured so that medical staff can determine whether the strategy led to improved patient safety 20 Articulation of Response Submission has no major errors related to citations, grammar, spelling, syntax, or organization Submission has major errors related to citations, grammar, spelling, syntax, or organization that negatively impact readability and articulation of main ideas Submission has critical errors related to citations, grammar, spelling, syntax, or organization that prevent understanding of ideas 10 Total 100%
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IHP 315 Final Project Case Studies For your final project, select one of the following case studies to use as the basis for your error analysis and recommendations paper. Case Study A Karen Viani was newly diagnosed with congestive heart failure one month ago. Her primary physician prescribed a number of medications: a beta blocker to slow her heart rate, Lasix to treat the fluid overload, and digoxin for control of her symptoms. She also takes a potassium supplement. Ms. Viani is 76 years old, slim, and lives with her pet dog, Alfredo. She was hospitalized on Friday at noon at Mesa Valley Hospital, a 60-bed acute-care facility. This was after seeing her primary doctor for increased shortness of breath and after gaining four pounds in 24 hours. The hospitalist ordered a one-time dose of Lasix 20mg IV on admission followed by a lab order to check electrolytes in one hour. Recent hospital patient safety survey results identified some areas of strength and weakness. Strong positive responses were in the categories of organizational learning and continuous improvement at 78%; teamwork also scored a high 80% positive response. Areas with potential for improvement were staffing at a positive response rate of 25% and non-punitive environment and safety culture had a positive response rate of 20%. The nurse responsible for care of Ms. Viani was very busy. She gave the Lasix three hours after Mrs. Viani arrived and after the lab had drawn the blood for the electrolytes. When the hospitalist arrived at 1630, she noted the lab report indicated that the potassium level was low. The hospitalist assumed that the blood was drawn after Ms. Viani had received the Lasix. The hospitalist ordered another Lasix 20 mg IV. The evening nurse noted the order at 1700 and gave the Lasix before dinner. During the evening mealtime, Ms. Viani suddenly felt light-headed, tried to reach the call bell that was on the bedside table, and fell on the floor. Ms. Viani sustained a small laceration on her forehead and a sprained right wrist, and then became quite disoriented and lost consciousness for a few seconds. The rapid response team (RRT) was notified and by the time the team arrived, Ms. Viani was lucid and was complaining of pain in her right wrist. The hospitalist ordered in the patient’s record that an incident report needed to be filed as the nurse made a medication error. The hospitalist has professional liability insurance as a condition of her employment at Mesa Valley. The nurse does not. Case Study B Twenty-year-old student, Paul, developed a right-sided pneumothorax while playing soccer at 1215. He had no prior remarkable medical history. His coach transported him to the Union Hospital Emergency Department at 1225, where he was triaged immediately due to his shortness of breath at 1250 and was seen by the emergency room doctor at 1300. Union Hospital is a 150-bed Level III trauma facility located in Cimarron View, a city of 25,000. The latest hospital safety survey indicated categories of strength (positive response) were supervisor promoting patient safety at 75% and management support for patient safety at 70%. Weak areas were staffing at a survey positive response of just 25% and a low 15% positive response for hand-offs and transitions. A chest film confirmed a right lower-lobe pneumothorax. The doctor ordered a thoracotomy insertion tray; as soon as the equipment was provided at the bedside, the nurse inserted the chest tube into Paul’s left side. As time was of the essence, no consent was signed and a time out, usually performed in surgery, was also not done. Following the chest tube insertion, there was no improvement in Paul’s shortness of breath. At this time, the nurse informed the physician that the chest tube had been inserted on the wrong side. Paul was becoming increasingly agitated and the physician mentioned to Paul what had happened. The nurse noted in Paul’s record that an incident report was filed for the wrong-side insertion, following the doctor’s written order to do so. The emergency physician attempted to have Paul admitted as an inpatient to Union Hospital so that the reinsertion could be done in the operating room. The time now was 1345. The nursing supervisor informed the physician that there were no available inpatient beds at Union and Paul would need to be transported and admitted to Jefferson Memorial, five minutes away. As an ambulance was on standby at Union, the emergency physician ordered immediate transport and also communicated with the surgeon at Jefferson about Paul’s condition. The unit secretary had just returned from taking a late lunch break and did not see the transfer order. The nurse was admitting another patient to the emergency department. The emergency physician, after writing Paul’s transfer orders, was now dealing with a serious motor vehicle injury patient. Paul oxygenation status continued to decompensate and he lost consciousness. At 1430, the secretary noticed the order and clarified with the nurse. When the nurse went to reassess Paul, he had expired. The physician has professional liability insurance as a condition of his employment at Union. The nurse does not.