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Instructions:
Case study about influencing quality within healthcare
Root cause analysis is a two-part assignment.
SUMMARY PAPER
To access the case study of the Multifactorial Medication Mishap, please click here (Used with permission: Agency for Healthcare Research and Quality Patient Safety Network).
You will complete the root cause analysis worksheet to study the case further. If it does not open, simply right-click on the tab and select “Open in New Tab”. This opens the document, which is editable. In the event that you’re unable to open the attachment, see the document attached below.
The case of a multifactorial medication error A 50-year-old man who had recovered from a routine spine surgery was hospitalized because of a health issue. However, clinicians anticipated he would be ready to go from intravenous to oral
opioid painkillers prior to discharge. When the patient felt nauseous from pills, he admitted that he had previously ingested liquid opioid painkillers without issue. The nurse mentioned to the doctor that the patient was in a lot of pain and previous patients had found that intravenous (IV) administration of liquid opioids worked well. Two types of tablets and two for liquid oxycodone were found in the computerized prescriber order entry (CPOE) system when the physician
searched for the drug in the system (the standard 5 mg per 5 mL concentration and a more concentrated 20 mg per mL formulation). Under this hospital’s CPOE system, both the generic name and the brand name were listed for each
selection. There were eight different kinds of oxycodone products that the doctor examined. The doctor ordered a 5-mg dose of the concentrated oxycodone liquid product. All medication orders at the hospital had to be verified by a pharmacist before they could be given to patients. Because the concentration of the higher concentration was thought to be particularly unsuitable for inpatient patients, the pharmacist thought the volume of fluid given to the patient would be
lower with this choice. This pharmacist confirmed the order, added a comment to both the electronic medication administration record (eMAR) and the patient-specific label to highlight that the administered dosage was 0.25 mL, and this procedure reduced the risk of error (5 mg). a calibrated syringe was given to the bedside nurse to confirm that this was a high concentration formula, with a volume of 0.25 mL. (a smaller volume than would typically be delivered). A short time
after that, the nurse arrived at the patient’s bedside to administer the medication for the pain he was still experiencing. She first filled a 2.5 mL (50 mg) vial with liquid oxycodone and left it with the patient before leaving for her break. The nurse
discovered the patient was unconscious and called for assistance with a code blue. The patient recovered and became more alert after he was given naloxone (an agent that cancels the effects of opioids). The treatment team decided to keep
him in the ICU so that they could continuously monitor him and administer naloxone to counteract the effects of the oxycodone. As a result, the patient returned to his original state of health by the following morning with no apparent ill effects.
Format The two files must be submitted. Summarize a nonfiction work in 525 words, using APA 7th citation format.
In order to investigate root causes, conduct a root cause analysis.
Because root cause analysis is performed, why is/is it performed?
Evaluate the reason for conducting a root cause analysis in this instance.
Use of RCA, FMEA, and PDSA like tool can impact quality and safety in patient care.
In essence, you learned and will now be able to apply this knowledge.
Ensure the root cause analysis is connected to your paper or is included as a *appendices. References in APA-formatted reference pages must include at least two sources from reliable peer-reviewed or evidence-based publications published within the last five years. Please upload your worksheet and synopsis.
Case study about influencing quality within healthcare
RUBRIC |
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Excellent Quality 95-100%
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Introduction
45-41 points The background and significance of the problem and a clear statement of the research purpose is provided. The search history is mentioned. |
Literature Support 91-84 points The background and significance of the problem and a clear statement of the research purpose is provided. The search history is mentioned. |
Methodology 58-53 points Content is well-organized with headings for each slide and bulleted lists to group related material as needed. Use of font, color, graphics, effects, etc. to enhance readability and presentation content is excellent. Length requirements of 10 slides/pages or less is met. |
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Average Score 50-85% |
40-38 points More depth/detail for the background and significance is needed, or the research detail is not clear. No search history information is provided. |
83-76 points Review of relevant theoretical literature is evident, but there is little integration of studies into concepts related to problem. Review is partially focused and organized. Supporting and opposing research are included. Summary of information presented is included. Conclusion may not contain a biblical integration. |
52-49 points Content is somewhat organized, but no structure is apparent. The use of font, color, graphics, effects, etc. is occasionally detracting to the presentation content. Length requirements may not be met. |
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Poor Quality 0-45% |
37-1 points The background and/or significance are missing. No search history information is provided. |
75-1 points Review of relevant theoretical literature is evident, but there is no integration of studies into concepts related to problem. Review is partially focused and organized. Supporting and opposing research are not included in the summary of information presented. Conclusion does not contain a biblical integration. |
48-1 points There is no clear or logical organizational structure. No logical sequence is apparent. The use of font, color, graphics, effects etc. is often detracting to the presentation content. Length requirements may not be met |
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Case study about influencing quality within healthcare |
Case study about influencing quality within healthcare