Improving Patient Safety and Quality of Care Essay Essay

Assignment QI in Patient care: A Case Study
QI in Patient Care: A Case Study
Note: A lot of case studies can be found here: https://www.patientsafetyinstitute.ca/en/toolsResources/Member-Videos-and-Stories/Pages/default.aspx Improving Patient Safety and Quality of Care Essay Essay

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You will describe a patient situation in which there was an adverse event or a near miss—i.e. a quality of care failure due to an error in some aspect of the patient care. This can be something you have seen yourself or that you found online. The case study should have the following details:

A patient related situation happened that either injured the patient or had a high probability of injuring the patient (a near miss).
There is a chain of events leading to the injury or near miss.
One or more errors happened in that chain of events. An example of a chain of events is the following: “The doctor wrote a correct drug order, the pharmacist didn’t read the order carefully and sent up the wrong drug, and then the nurse didn’t check to see it was the wrong drug and administered it to the patient. As a result, the patient suffered a cardiac event and had to be transferred to the Intensive Coronary Care Unit. The patient survived, but just barely.” Improving Patient Safety and Quality of Care Essay Essay
The situation is interdisciplinary and relies on a team approach for improvement. (In the example above, both nursing and the pharmacy are involved
Based on this case study, you review and analyze this case and discuss it within your teams. Your discussion should include the following:
Analyze your patient case using root cause analysis
Identify the factors that contributed to the error, and specify which were most important to the error happening. Remember, most errors are at least partially caused by problems with the care delivery system or other systems
Based on the errors you found, identify one or more changes that must be made to prevent the error from happening again or at least make it much less likely. Improving Patient Safety and Quality of Care Essay Essay
Prioritize the changes needed. The first change should focus on the factor most important as a cause of the error. Other changes that might also need to be made (recognizing that once the most important cause is addressed some of the other factors might not still exist). Remember, educational interventions are appropriate ONLY when you have assessed the people involved and found the cause to be a lack of knowledge. Frankly, this isn’t often the problem. Improving Patient Safety and Quality of Care Essay Essay
Develop a plan for making the first change and note if that will eliminate any other causes. Remember to include information on how two or more departments or disciplines will have to collaborate on how to correct the problem.

Write a paper with the above information. The paper will be in APA format and no more than 6 pages, not including title and reference pages. This assignment is due at the end of Unit 3. Improving Patient Safety and Quality of Care Essay Essay

Follow the Grading Rubric below to ensure all required areas are covered in your paper.

QI Case Study Paper Rubric and Writing guide

Criteria

Possible Points

Earned Points

Description of the error that occurred Improving Patient Safety and Quality of Care Essay Essay

10

Chain of events leading to the error

10

Root Cause analysis and factors leading to the error

20

Causes prioritized

15

Changes needed to prevent the error from happening again

10

Identification of the most important factor that led to the error Improving Patient Safety and Quality of Care Essay Essay

10

Plan for improvement (correction of first factor leading to the error) using the Plan Do Study Act approach

20

APA Format

5

Total Points

100

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