ORGANIZATIONAL SYSTEMS & QUALITY LEADERSHIP

| May 23, 2015

Task:
4 to 5 pages

  1. Complete a root cause analysis (RCA) that takes into consideration causative factors that led to the sentinel event (this patient’s outcome).
  2. Discuss errors or hazards in care in the scenario.
  1. Use change theory to develop an improvement plan to decrease the likelihood of a reoccurrence of the outcome of the scenario.
  1. Use a failure mode and effects analysis (FMEA) to project the likelihood that the process improvement plan you suggest would not fail.
  • Identify the members of the interdisciplinary team who will be included in the RCA and FMEA.
  1. Explain how you would test any interventions to improve care in a similar situation by changing the process of care.
  2. Discuss pre-steps for preparing for the FMEA.
  3. Describe thethreesteps of the FMEA: severity, occurrence, and detection.

Note: You are not expected to carry out the full FMEA, but you should describe each step and how you would go about it.

  1. Discuss the key role nurses would play in improving the quality of care in this situation.
  1. When you use sources to support ideas and elements in a paper or project, provide acknowledgement of source information for any content that is quoted, paraphrased or summarized. Acknowledgement of source information includes in-text citation noting specifically where in the submission the source is used and a corresponding reference, which includes:
  • Author
  • Date
  • Title
  • Location of information (e.g., publisher, journal, or website URL)

Note: The use of APA citation style is encouraged but is not required for this task. Evaluators will offer feedback on the acknowledgement of source information but not with regard to conformity with APA or other citation style. For tips on using APA style, please refer to the APA Resources web link found under General Information/APA Guidelines in the left-hand panel in Taskstream.

Note: No more than a combined total of 30% of a submission can be directly quoted or closely paraphrased from outside sources, even if cited correctly. Note: When bulleted points are present in the task prompt, the level of detail or 

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