The Quality Risk Management Plan

1331 WordsJun 29, 20156 Pages
The quality risk management plan for this case study scenario includes identifying areas of risk and healthcare errors, in order to protect future patients from having their safety compromised. The case study describes two patients who received wrong-site surgery; which is considered a sentinel event – preventable and should never occur. According to a report by the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network (2015) titled Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery, wrong-site surgery is the most frequent type of sentinel event. It is approximated that wrong-site surgeries take place forty times per week in America (Clark, 2011). Wrong-site surgery has been identified as a top priority in improving quality of care and increasing patient safety. As such, The Joint Commission 2015 Hospital National Patient Safety Goal includes the prevention of mistakes in surgery. The goal is to perform the correct surgery on the correct patient at the correct site, prior marking of the surgical site, and performing a time-out just prior to commencement of the surgery. The purpose of this paper is to create a root-cause analysis, present recommendations for improvement, present recommendations to prevent wrong-site surgery, identify the stakeholders and role players, present root-cause analysis charts, and provide an overall of lessons learned throughout the course. Root-Cause Analysis A root-cause analysis is a method used to identify causal
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