Discussion: Quality Risk Management Plan
Discussion: Quality Risk Management Plan
Question Description
For your final Portfolio Project, you will write a paper detailing a risk management plan based on the following case study scenario. Your goal is to identify areas of risk and healthcare/medical error, and to safeguard future patients from having their safety compromised in a manner similar to what occurred in this case study. Your risk management plan must include:
A root-cause analysis
At least three recommendation(s) for improvement
Two recommendations for how this situation could be avoided
Identification of all roles in your analysis
Quality, risk, and performance improvement diagrams and charts to support your analysis (e.g., a fishbone or other visual form of root-cause analysis, Pareto chart, tables, etc.)
Commentary that relates the case broadly to what you have learned throughout the course and describes the roles played by quality management and regulation to prevent unfortunate occurrences such as the case described
Your paper should meet the following requirements:
Be 10-12 pages in length, NOT INCLUDING THE COVER OR REFERENCE PAGES.
Be formatted according to the CSU-Global Guide to Writing and APA Requirements.
Provide support for your statements with in-text citations from a minimum of eight (8) scholarly references—four (4) of these references must be from outside sources and four (4) may be from course readings, lectures, and textbooks. The CSU-Global Library is a good place to find these references.
Utilize headings to organize the content in your work.
The case is as follows:
You are the Chief Risk Management Officer for a large metropolitan not-for-profit teaching hospital. You have been assigned this case by the Chief Executive Officer due to the potentially sensitive nature of the situation and the CEO’s personal interest in disadvantaged and ethnic minority population groups. Your goal is to do a thorough risk analysis and create a risk-management plan as part of the overall quality management program for this facility based on the following case scenario.
A female patient, age 25 years, presents in the emergency room with pain in the right side of her lower abdomen. Her last name is Jonesky. She has been ill and vomiting for two days. The patient is triaged and asked to take a seat in the emergency room waiting area until she can be seen. Additionally, the patient speaks only Russian, and her husband, who is the only family member with her, speaks limited English, with Russian being his primary language.
Several hours have passed and the patient is still sitting in the emergency room, in extreme pain. The husband approaches the emergency room desk to try to communicate that his wife is worsening and in extreme pain. After several minutes of discourse, the patient is taken back into an examination room to be seen.
She is diagnosed with appendicitis and requires removal of her appendix. She is sent to a holding area outside of the operating room where she will wait to be taken into surgery. Upon her arrival, a nurse asks her name and due to the fact that the patient only speaks Russian, her name, “Jonesky” sounds very much like “Jones” to the nurse. Then anesthesiologist arrives and interviews the patient. Simultaneously, another emergency patient is brought into the holding area of the operating room. Her name is Samantha Jones. Samantha has fallen down icy steps and has broken her left ankle, which now needs to be repaired. This is a very busy night for the operating room. Additional staff members, who have already worked a full eight-hour shift, are called in to attend to this second case.
Both patients are interviewed and taken into ORs for their procedures. Since it is late, both surgeons do the required time-out procedure, but not as judiciously as they would have during the day. Staff members in attendance for both cases implicitly go along with their surgeon’s order and surgery following a time-out procedure that was not complete. As the first surgical procedure begins, the surgeon makes an incision into Mrs. Jonesky’s ankle and there is no sign of any broken bone. He realizes there is a problem. Additionally, in the second OR, the surgeon operating on Samantha Jones makes an incision and finds no sign of appendicitis. Both surgeons operated on wrong sites due to incorrect identification of the patient.
Discussion: Quality Risk Management Plan
You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.
Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.
Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.
The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.
ADDITIONAL INSTRUCTIONS FOR THE CLASS
Discussion Questions (DQ)
Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.
Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.
One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.
I encourage you to incorporate the readings from the week (as applicable) into your responses.
Weekly Participation
Your initial responses to the mandatory DQ do not count toward participation and are graded separately.
In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.
Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).
Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.
APA Format and Writing Quality
Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).
Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.
I highly recommend using the APA Publication Manual, 6th edition.
Use of Direct Quotes
I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.
As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.
It is best to paraphrase content and cite your source.
LopesWrite Policy
For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.
Late Policy
The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
I do not accept assignments that are two or more weeks late unless we have worked out an extension.
As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.
Communication
Communication is so very important. There are multiple ways to communicate with me:
Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.
Root-Cause Analysis and Safety Improvement Plan Scoring Guide
| Criteria | Non-performance | Basic | Proficient | Distinguished |
|---|---|---|---|---|
| Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization. | Does not identify the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization. | Identifies the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization. | Analyzes the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization. | Analyzes the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization, noting the degree to which various elements contributed to the safety issue or sentinel event pertaining to medication administration. |
| Apply evidence-based and best-practice strategies to address the safety issue or sentinel event pertaining to medication administration. | Does not describe evidence-based and best-practice strategies pertaining to medication administration. | Describes evidence-based and best-practice strategies but their relevance to the safety issue or sentinel event pertaining to medication administration is unclear. | Applies evidence-based and best-practice strategies to address the safety issue or sentinel event pertaining to medication administration. | Applies evidence-based and best-practice strategies to address the safety issue or sentinel event pertaining to medication administration, detailing how the strategies will address the safety issue or sentinel event pertaining to medication administration. |
| Create a viable, evidence-based safety improvement plan for safe medication administration. | Does not create a viable, evidence-based safety improvement plan for safe medication administration. | Creates a safety improvement plan for safe medication administration that lacks appropriate, convincing evidence of its viability. | Creates a viable, evidence-based safety improvement plan for safe medication administration. | Creates a viable, evidence-based safety improvement plan for safe medication administration that makes explicit reference to scholarly or professional resources to support the plan. |
| Identify existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration. | Does not identify existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration. | Identifies existing organizational resources, but their relevance and usefulness to quality and safety improvement for safe medication administration are unclear. | Identifies existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration. | Identifies existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration, prioritizing them according to potential impact. |
| Organize content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling. | Does not organize content for ideas. Lacks logical flow and smooth transitions. | Organizes content with some logical flow and smooth transitions. Contain errors in grammar or punctuation, word choice, and spelling. | Organizes content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling. | Organizes content with a clear purpose. Content flows logically with smooth transitions using coherent paragraphs, correct grammar or punctuation, word choice, and free of spelling errors. |
| Apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format. | Does not apply APA formatting to headings, in-text citations, and references. Does not use quotes or paraphrase correctly. | Applies APA formatting to in-text citations, headings and references incorrectly or inconsistently, detracting noticeably from the content. Inconsistently uses headings, quotes or paraphrasing. | Applies APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format. | Exhibits strict and flawless adherence to APA formatting of headings, in-text citations, and references. Quotes and paraphrases correctly. |
