Failure Modes And Effects Analysis

The main objective of Beaumont Hospital is to provide high quality, efficient, accessible services, in a caring environment for Southeastern Michigan residents. Beaumont Hospital believes that patient safety is just as important as medical progression. Therefore, Beaumont Hospital’s risk management program consists of identifying hazard associated risks, controlling risks, and monitoring the effectiveness of procedures/practices. Risk is a part of patient care and services because everything doesn’t always go according to plan. Catastrophic patient injuries often occur because of unanticipated failures. The risk management team is responsible of effective surveillance, analysis, and prevention of events which may injure patients, lead to malpractice claims, or cause loss to the health care system. The risk management staff at Beaumont use the Failure Mode and Effects Analysis (FMEA) as a tool to anticipate what might go wrong with a process or product and how that failure effects the patient. FMEA is designed to dissect a particular process into its individual steps, isolate the potential steps that could cause the problem, assign a specific risk level to each abnormal step, analyze the risk potential for the process, and assign and action plan to correct the problem (Fibuch & Ahmed, 2014). The risk management team also evaluates and modifies potential problems. Beaumont Hospital’s risk management team helps avoid or eliminate risks by identifying an alternate

This paper will analyze the cause of the sentinel event which occurred to Mr. B, a sixty seven year old patient which presented to the emergency room with left leg pain. A root cause analysis will be necessary in this case to investigate the causative factors which led to Mr. B’s sentinel event. The factors in this unfortunate case weather they were errors in his care, or hazards in the system will be identified. The Change theory will be used to develop an improvement plan that will be used to decrease the chances of a reoccurrence of the sentinel event that happened to Mr. B. in the scenario.

A. A complete root cause analysis (RCA) that incorporates the causative factors, errors, and hazards that led to the patient’s outcome or sentinel event.

A root cause analysis (RCA) looks at an event and considers what happened, why it happened what will be done to prevent it from happening again and how will we know that the changes made will improve the safety of the system. It takes into consideration causative factors, errors and hazards that led to a sentinel event. In this case it was a patient’s death. RCA should not look to place blame on people, but rather processes that need to be improved.

Never events are serious medical errors that are often preventable. When such events transpire, it is necessary to fully assess the situation so that these errors can be prevented in the future. Root cause analysis (RCA) is a tool employed by healthcare facilities to analyze adverse events and the systems that lead to them.

Patient safety and risk management should be intertwined in the organization. Patient safety is where the patient does not experience unnecessary harm or pain or other suffering during their treatment (Youngberg, 2011). Minimizing risk is to decrease unnecessary losses or improve or implement process that will decrease adverse event (Youngberg, 2011). The Samantha Jones adverse event is a perfect example to enhance patient safety through improved process or project. To understand the event a root analysis needs to be done and action items are created from this analysis.

Michael Fitzgerald's, "Splendid Failure" describes the unfolding tensions of the rebuilding of the United States after it’s horrid war the nation went through. In this essay, we will discuss three things. The government, the freedmen, and explain who’s at fault, the North or the South and discover why Michael Fitzgerald finds it all, a Splendid failure.

A root cause analysis (RCA) is a method by which we can examine a serious adverse event and identify the cause, or causes, that led up to the event. Although personnel are involved in these events, the primary purpose of the RCA is to identify the cause, not to assign blame (Agency for Healthcare Research and Quality, 2014). It is through identifying a cause, or causes, of an adverse event that we can improve on patient care processes and thereby patient safety. The RCA is designed as a specific protocol that starts with data collection looking at the sequence of events that led to the

A root cause analysis (RCA) is an essential tool that can be used to examine and understand the ways in which systems fail as well as discuss those specific failures that led to a specific adverse event and potentially implement steps or behaviors to prevent that event from happening in the future (Ogrinc & Huber, 2013). In the case study presented, a number of system failures may have contributed to the patient outcome. As such, an RCA of the case study would help determine those specific

The videos of officer Norman is an example of community justice. Officer Norman shows a lot of empathy with the families in Arkansas which makes them feel safe in their community. You can tell that where they're from is low income and the crime rates are probably high, so by him interacting with the children and adults shows that he truly cares about his community. This corresponds to chapter one because this chapter explains the different rolls of community justice which is what officer Norman portrays. Community justice is all about doing good for your community and making the environment that you live in better each and every day. on the other hand, the article that talks about "the broken windows theory" portrays

With reference to case studies, critically evaluate the success of management schemes in fragile environments (40 marks)

Throughout the United States of America, our infrastructure demands to be repaired. Since the rapid expansion of our infrastructure in the early to mid 1900’s, the basis of our nation, the infrastructure we rely upon, has outlived its life. At this very moment, money, an item in high-demand, is lost due to a large quantity of failures within our infrastructure. Everyday, sewage lines leak, gas pipelines explode, roads crumble and form potholes, power outages occur, and many other infrastructure failures take place. As the United States of America seeks to expand its economy, the need to renew the rapidly aging infrastructure should not be neglected.

Thank you for sharing your knowledge Charmaine. I would also like to commend you Sarju, for highlighting the U.S. Veterans Affairs’ (VA) RCA procedures which caught my attention. However, in addition to your shared reading, I also found that their RCA process centers on the “how” and the “why”? not on the “who”. Furthermore, the VA’s RCA procedure is utilized to identify approaches to prevent adverse events which is a part of their campaign to create a culture of safety and shift away from the culture of condemnation. Moreover, the RCA team comprised of multidisciplinary specialist including the frontline members, and individuals with familiarity of the event. The RCA process also continuously investigates by wanting to know the answer to why,

In 2008, author J.K. Rowling wrote and gave a commencement speech to the graduating class of Harvard University. Rowling aptly named the speech “The Fringe Benefits of Failure, and the Importance of Imagination”. In this speech Rowling tries to convey the message that failing can be beneficial or an individual and that people should not be afraid to use their imagination. Rowling begins the speech with a reflection on what went through her mind while writing the speech and how the process affected her. During this time Rowling asked herself what she wished she had known at her graduation and came up with the two main ideas of this speech; the merits of failure and significance of imagination. Rowling explains the benefits of failure by using her own personal failure of living in poverty with her daughter and what that failure taught her. For the significance of imagination, Rowling describes it not in terms of how it helped her out of poverty, but of how it opens up people to the world and other individuals around them.

As my first semester of college is coming to an end, I would like to reflect on my experience here within the Honors 120 and 121 class on Failure and the Question Wheel. I chose this class on failure because I have always held myself to such high standards that I hoped to be able to find a way to accept failure in some instances. Within our first week in class, we made claims about failure. My favorite claim was that every failure is in some way a success. Although this claim was not very debatable and incredibly generic, I was able to really let my mind explore what it was trying to say. Throughout the semester I experienced failure after failure, but that allowed me to see that success can still be achieved within failures.