Task 2 RTT

If you look at the Rubric measures and identify the concepts from each, it should help you outline the paper.

The concepts you are writing about include:

(the order presented below is based upon the most current version; early versions may be organized slightly differently but the requirements for your papers content are the same)

  1. Root Cause Analysis: What is an RCA, identify from the scenario the errors and hazards. You are identifying the factors (errors and hazards) that led to the sentinel event.  Give an overview of the scenario then speak to the errors made and hazards contributing to the event.
  2. Once you have presented all the errors and hazards, propose one process change or intervention (that you can measure/or monitor during implementation, section C4), which addresses one (or more) that would reduce the likelihood of the same error.
    1. Present one change theory and describe it
    2. Give an example or two of what you might do to apply the components of the theory, to your plan, to improve the likelihood the staff impacted by the change will buy-in.
  3. FMEA: this section just applies to your intervention or change.  It is a process that looks at possible barriers or failures that could interfere with your plan if not considered.  FMEA is a proactive versus retrospective tool.
    1. For the major header it should be a summary of what FMEA is and once complete your plan/intervention or change in process will be more likely to be successful. Answer the question; How did the FMEA process prevent a plan failure?

C1.  Interdisciplinary team:  what staff or Departments will your plan impact.  Who needs to help define the new process steps?

C2.  Pre-steps or preparing for evaluating possible failures (modes):  This section asks you to identify/name what you as a leader would do to start looking at the possible failures.  The best reference is the FMEA tool in Week 3 of your COS and is attached.

C3. FMEA process:  Pick one possible reason your plan may fail and present and rank the severity, likelihood it would occur and how easily you could detect the failure.  Use the number ratings and explain how you would arrive at an rpn number and generally what you would do as a result, if you were to rate/rank every possible failure mode.

C4  Testing Interventions:  Propose a specific interval evaluation plan or pilot to continuously monitor whether your plan is working and leading to fewer errors.  How many events will you include, who will do it,  what data could you use, over what period of time would the trial last.  There is a lot of information in the QI modules about this.  One example is the PDSA process where “s” is study or testing the intervention.

  1. How can professional nurses contribute to QI processes? Why is this an important leadership role for professional nurses.
    1. The Cherry text has a great overview of this concept as does IHI in general, as to why QI has become so important.
    2. Another site to check out is the ANA website, search NDNQI to read about this survey and how many nurses are involved in QI and research related patient safety and improving patient outcomes.




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