Organizational Systems and Quality Leadership

2095 Words9 Pages
Organizational Systems and Quality Leadership Task 2 Mark Woodard Western Governors University 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. Root…show more content…
Improvement Plan An improvement plan using the change theory needs to be used to decrease the likelihood of a reorrurance of the sentinel event that led to the death of Mr. B. in the scenario. The change theory which would be best suited for this scenario would be The Model for Improvement. The first part of the model has three fundamental questions. The first part is called, Aim: What are we trying to accomplish? The second part is, Measures: How will we know a change is an improvement? The third part is called, Changes: What change can we make that will result in improvement? The second part of The Model for Improvement is the PDSA cycle. This is the testing phase of the model. The acronym PDSA stands for Plan, Do, Study, and Act. This is a four step process which is a simple way to test and make changes to the process. If The Model for Improvement is applied to Mr. B’s scenario, the aim of the improvement plan would be to make sure that patients coming into the emergency room receive the appropriate dose of medications, that the patients are monitored correctly, and that the staff is educated about proper medication administration. The measures part, How will we know a change is an improvement, could be answered by compiling data with the number of patients receiving hydromorphone in the emergency room, what type of monitoring was used
Open Document