Week 5: When We Fail to Provide High-Quality, Safe Care
Nurse executives may be tasked with evaluating adverse safety events—either individually or as part of an interdisciplinary team—to prevent them in the future. An evaluation may consist of analyzing every step in the patient’s care process to see what did and did not occur. Tools like the process map allow this kind of step-by-step view.
For this assignment, you will read about two real cases that resulted in negative outcomes and—much like a root cause analyst—examine what went wrong from a quality and safety standpoint.
Post a response that addresses the following questions for the case you have chosen:
· In what way did the system fail the patient and his family?
· What communication problems are apparent in the case?
· Where in the process of care did incidents (errors, near misses, adverse events, and harm) occur?
Patient Safety Movement. (n.d.). Patient story: Lewis Blackman. Retrieved from https://patientsafetymovement.org/advocacy/patients-and-families/patient-stories/lewis-blackman/
Johnson, J., Haskell, H., & Barach, P. (2009). Lewis’ story—It’s hard to kill a healthy 15-year-old. Retrieved from http://www.healthwatchusa.org/conference2013/PDF-Downloads/Haskell-Lewis_Blackman_Story.pdf
Institute for Healthcare Improvement. (n.d.c). Noah’s story: Are you listening? Retrieved from http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/NoahsStoryAreYouListening.aspx
Ricciardi, R., & Shofer, M. (2019). Nurses and patients: Natural partners to advance patient safety. Journal of Nursing Care Quality, 34(1), 1–3.
Agency for Healthcare Research and Quality. (2019e). Systems approach. Retrieved from https://psnet.ahrq.gov/primer/systems-approach
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