13 pages
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You will use a root cause analysis to determine what caused a patient to receive the wrong medication, what should be done about this, and how this type of error could be prevented in the future.
Prompt
The local hospital had an incident involving the wrong medication administered to a patient. You have been asked to perform a root cause analysis. First, you need to discover the event that happened, how it happened, and why it happened. Then in your response, address the following elements:
· Recommend key stakeholders to investigate this case. Why should these stakeholders be involved with the investigation?
· Compare the Five Whys of medication administration. How could addressing these questions help identify the root cause of this problem?
· How could medication errors be avoided in the future?
In this paper, address the following two components:
1. Determine how the two quality initiatives below lead to performance improvement for healthcare organizations:
· Pay-for-performance incentives on quality, i.e., MACRA
· Healthcare Quality Improvement Act
2. How are multi-voting tools utilized when deciding on a quality improvement initiative?
Problem identified: Shortage of staff in hospitals
What Is the Organizational Problem?
a. Provide details about the organizational problem. How does this problem fail to meet quality or other regulatory requirements?
b. State organizational challenges posed by the problem (e.g., interdepartmental conflicts, communication failure, budgeting issues).
Evidence-Based Support
a. Provide data that supports the existence of the problem. You may use public sources to find data related to your problem. Be sure to de-identify any patient data if you are using your organization’s problem.
b. How has this problem been addressed in the past? What information management systems or patient care technologies have been used when addressing this problem? Be sure to use peer-reviewed literature to support your answer.
c. Discuss relevant accreditation standards, safety standards, compliance standards, and quality initiatives. How do these standards promote a culture of safety within the department? Be sure to cite the appropriate standards within your answer.