Examples Of Data Management

Environmental Factors: The hospital is a very busy place. The background noise can distract the attention of the physicians while they ponder over the right prescription of a drug. The high demand of a medical profession can be stressful and lead to fatigue. These possible occupational hazards can contribute to medical errors.

* Instructors with administrative rights must sign an agreement and are responsible for their own support.

One of the most critical factors which contribute to the number of preventable cases of healthcare harm is the culture of silence surrounding these cases. The fear of medical providers to report incidences is related to the possibility of punishment and liability due to a medical error (Discovery, 2010). The criminalization of some acts of medical error has resulted in job dismissal, criminal charges and jail time for some healthcare workers. This is despite the fact that the system they are working in helped to create the situation which led to the error in the first place. Human error, due to fatigue and system errors can result in deadly consequences, but by criminalizing the error it effectively shuts down the ability to correct the root problem. Healthcare workers, working at all levels within the medical system, can provide valuable input on how to improve the processes and prevent harm from occurring (Discovery, 2010).

Root cause analysis process will utilize a systematic step-by-step approach to help identify all causative factors leading to this sentinel event. The main purpose of the Root Cause Analysis is to understand how the event happened, why did it happen, and what can be done to prevent an event from happening again. The first step, collect all necessary data associated with this event such as: current policy and procedures, incident report, Mr. B’s health history, environmental flowcharts, dispensed medications, equipment and staffing factors relevant to the event. The process of identifying causative factors can begin once all the data is collected. The goal, of a Root Cause Analysis, is to identify interventions to prevent an event from reoccurring.

The process is an action plan that tends to illuminate on the strategies to be employed with the purpose of reducing the risk of a similar sentinel event such as that of Mr. B’s scenario. It addresses the responsibility for the oversight, implementation, pilot testing, as well as timelines and strategies for the measurement of actions that are effective (Lewis et al, 2014). All the root cause analysis (RCA) findings conducted above should help in the determination of the appropriate action plan. The appropriate improvement plan in this scenario should encompass the reevaluation of the events that led up to the code blue of Mr. B. The plan should look at the staffing mix, if the licensed personnel are trained appropriately, the patient to nurse ratio in the ER and the types of patients that were in the ER at the time. When

• Record all hazards in the appropriate log, i.e. care plan, staff handover notes, accident book etc.

A root cause analysis is a systematic approach utilized to identify problems within an event and create a plan for preventing that problem from recurring in the future. To be effective, a timeline of the events are created to help identify those areas that may be the reason for the problem or event, and the relationship between the causal factors and those factors identified to be a reason for the event to have occurred.

Human interaction between individuals and systems does not occur in a vacuum, rather it occurs in a dynamic and multidimensional setting. From a structural and procedural system performance perspective, the nursing care environment “is perfectly designed to get the results it gets” (LLoyd, Murray, & Provost, 2015). When mistakes happen in healthcare, all Joint Commission accredited healthcare organizations are obligated to analyze the care environment to assess for opportunities to improve the structural and procedural elements that lead to care failures, as in the fictitious sentinel event case of Mr. B who presented to the emergency department for a

The provided scenario gives an account of a busy emergency department with competent staff, and the multiple errors that led up to the most severe error possible in healthcare, unnecessary death of a patient. A root cause analysis (RCA) can be utilized to help understand the systems at fault within the facility so that improvements can be determined and implemented to prevent any future occurrences (Cherry, 456). RCAs focus on systems rather than blaming individuals involved, therefore they are only appropriate in cases where there has been no willful negligence or criminal acts (Huber & Ogrinc, 2014). The overall purpose of RCAs is to find out the causes of the adverse event and determine how to keep similar errors from

A root cause analysis is defined as, “a process for identifying the basic or causal factors that underlies variation in performance, including the occurrence or possible occurrence of a sentinel event” (Cherry & Jacob, 2011, p. 442). Involved participants, in the case, the emergency room physician, registered nurse, and licensed practical nurse present during the sentinel event, as well as the emergency room nurse manager, and Chief Nursing Officer, should meet to discuss the events leading up to the patient’s (Mr. B’s) death and establish a root cause analysis. They should explore all hazards and errors in Mr. B’s care. Data should be gathered, facts surrounding the death analyzed, and causative factors should be explored to establish

Elliott, M., Page, K., and Worrall-Carter, L. (2012). Reason’s accident causation model: Application to adverse events in acute care. Contemporary Nurse, 43(1), 22-28.

After careful analysis of what had happened and what should have happened takes place, the RCA team should ideally focus on why the adverse events happened. In this step, the goal is pinpoint the direct causes and contributory factors (Ogrinc & Huber, 2013). By doing this, the root cause of an event can be identified. One suggestion made by the Institute of Healthcare Improvement in the root cause analysis process is to ask “Why?” five times (Ogrinc & Huber, 2013).

Gathering information from available sources: With the use of tracking Cumulative Trauma Disorders (CTDs), the information provided on existing medical, safety, and insurance records, including the OSHA 300 forms, could help provide any evidence for ergonomic hazards at the workplace. (Gortsch, 2011)

The purpose of this paper is to analyze the unfortunate sentinel event of Mr. B, a sixty-seven-year-old patient presenting with severe left leg pain at the emergency room. A root cause analysis is necessary to investigate the causative factors that led to the sentinel event. The errors or hazards in care in the Mr. B scenario will be identified. Change theory will be utilized to develop an appropriate improvement plan to decrease the likelihood of a reoccurrence of the outcome of the Mr. B scenario. A Failure Modes and Effects Analysis (FMEA) will be used to project the likelihood that the suggested improvement plan would not fail. Lastly, key roles nurses would play in improving the quality of care

Reporting errors can strengthen the processes of care and also enhance the quality of care. To effectively avoid further errors that can cause harm to patients, improvements must be made on the incidents or events reported in reporting system. Reporting errors can help the organizations better understand what happened, identify the factors that cause the occurrence of errors or incidents, determine its frequency and predict whether it could happen again and find an intervention to prevent or to