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NURS 8300 Week 9: The Application of Quality Improvement Models in Organizations and Systems
Wrong-side surgeries, hospital acquired infections, medication errors, and wrongful deaths-these sorts of medical mistakes often make headline news. How can these types of errors be prevented? Throughout this course, you have been examining methods for systematically improving the quality of care and patient safety within a health care organization. Another tool that can be used to evaluate medical and system errors is a root cause analysis.
This week, you explore root cause analysis, which is one of the key methods used in health care organizations to understand and address patient safety situations.
Learning Objectives
By the end of this week, you will be able to:
- Apply qualitative and quantitative methods to identify root causes of a specific quality improvement need
- Evaluate adverse events or factors that lead to a specific quality improvement need
- Formulate goals from collected data
Discussion: Root Cause Analysis
Note: Weeks 8 and 9 are linked together in an assignment that is completed within your group. Each group will receive the same grade for the final powerpoint submission at the end of Week 9. Each individual will receive a unique grade in Weeks 8 and 9 which is based on your individual contribution to the small group discussion boards as well as your participation in the final Week 9 discussion as well as the slides that you contribute to the powerpoint.
Root cause analysis (RCA) is a standard tool used to help health care organizations learn from errors, particularly those that result in harm. RCA is applied to address three key questions about a particular situation:
- What happened?
- Why did it happen?
- What can be done to prevent it from happening again?
To prepare for and complete this Discussion:
As a case study team, prepare a 10 slide power-point using tools provided in this case study to present your rationale and validation of the root causes your team has chosen. Be sure to include at least 4 peer reviewed research studies which evoke validation of the latest patient safety evidence in support of your root cause findings. Also address the extent to which this scenario evokes implication for value based purchasing.
To prepare for Week 9:
Continue your small group dialogue in dissecting the case study.
By Day 3
A designated team member will post the team powerpoint and key insights that your team has gained about your choices, this type of sentinel event, and use of root cause analysis in Week 9 discussion board.
By Day 7
Each student will respond to at least two other group PowerPoints and analysis.
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