Root cause

patient. Interestingly, these drastic scenarios can simply be prevented by following the patient identification protocols which usually rely on using two identifiers or more according to the policy in use. This paper uses the root cause analysis to identify possible actual causes that contribute to the recurrence of PIEs with special highlight to the emergency and surgery rooms. It

Chosen for root cause analysis is case study number 18, titled “Not for IV Use: The Story of an Enteral Tubing Misconnection” from the book Case Studies in Patient Safety: Foundations for Core Competencies. Root cause analysis is a process whereby error producing system factors are identified and reviewed to assist in the formatting and implementation of solutions to prevent similar errors from reoccurrence (Wachter, 2012). This accounting of the patient’s experience located in the Systems-Based

1.3. Provide an example of an improvement project, tools used, and the outcomes that can be shared and spread to other health care providers. As the patient safety officer, I am involved in the frequent root cause analysis (RCA) that result in improvements due to a retrospective response to specific events. Likewise, I am involved in many patient safety and quality initiatives where information from occurrences is used to improve quality, such as the falls prevention program, hospital-acquired

CE00783-7- QUALITY AND PROJECT MANAGEMENT FOR TECHNOLOGY ASSIGNMENT 1 - Case Study – JEEVES PLC Your company manufactures and sells an electronic consumer durable product. This is a DOMESTIC ROBOT of (more or less) human appearance, which is designed to carry out a wide range of domestic chores. The machine looks like this: The machine is made of light alloy and is equipped with sensory apparatus (a form of radar) to enable it to move around without bumping into things. It is programmable

This root cause analysis team is multidisciplinary, the members being members of the relevant departments, but not involved with the event. A facilitator from the legal office arranges meetings, keeps minutes and writes up the final report. The charge of the root cause analysis team is to explore all potential causes of the event, sort and analyze these causes, identify risk reduction strategies, and implement a correction plan with a timeframe for completion and monitoring. The Root Cause

MAXIMIZING COALITION PARTNERSHIPS 1. The purpose of this background paper is to provide a possible solution to maximize coalition partnerships to provide to the AFSNCOA Commandant and other Strategic Leaders from across the force. The problem we will tackle is that “the Air Force does not do enough to get feedback on multinational operations from the field.” To accomplish this mission, we will bolster the Air Force Culture and Language Center (AFCLC) in order to create a feedback loop for leaders

Stress at work typically is not felt from a single occurrence. The summation of stress occurrences lead to stressors. Stressors are defined as an event or context that elevates levels of adrenaline forcing a physical or mental response. There typically is a "straw that broke the camels back" philosophy that builds negative stress (Bauer and Erdogan page 138). Furthermore, our world is rapidly changing. The world becoming a global economy, rapidly changing technology, and increased competition

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

Last week while at work I encountered a conflict with one of my client’s whose business is transitioning. The company will be transitioning from being part of one company to its own standalone company and this requires a great deal of preparation. Since I am doing the preparation work, one of the steps is to make sure that all of this client’s direct customer base has set up their new vendor id numbers for the new standalone company. I am responsible for making sure that each customer will receive

function lies in the hands of the professional boards. In both cases, there is a vast number of incidents that are reportable. The two cases use a medical examiner as one of the primary investigators. Additionally, there is the application of the cause analysis. In the end, the system of reporting of choice depends on their pros and cons. In Minnesota, the mandate