In the case study team assumes full senior leader support on the validation of the two root causes identified.

1. Review the literature to find at least 4 peer reviewed research studies which evoke validation of the latest patient safety evidence in support of your root cause finding (Only locate 1 peer-reviewed article).

2. At this point, the case study team determines recommendations using the latest evidence from the literature on what is needed within these two hospitals to address these significant root causes.

3. Assume a three-month implementation timeframe, recognizing that full realization may take longer.

4. Construct a straw man Gantt chart or project plan to capture all necessary components to move the recommendations forward.

Tasks for discussion week 9:

1. Critique problem and mission statements.

Team A:

Problem and mission statement: Correct procedure performed on patient by wrong doctor. The team identified the problem did not result in direct patient harm, but the process error had potential to cause direct patient harm. The mission statement included root cause analysis of the event with recommendations for improvement (monitor over 3-month period) and report findings with positive improvement at end of monitoring period.

Team B:

Problem and mission statement: Identified event as sentinel event. Noted full safety procedures in place over past five years. Mission to determine root causes of event and demonstrate successful plan for measurable improvement in three months or less.

Each team's problem statement provides the appropriate and concise evaluation of the event. Team B's mission statement provides for a time frame that is shorter for resolution given the gravity of the sentinel event.

2. Analyze team processes, review process flow chart and cause effect diagram, data presented in two graphs and one table.

The flow chart with the notes on the procedures/practices and policies and the survey with staff with the nurse - physician interaction sharply contrasts with the results of the two bar graphs indicating positive results with training and sign off on universal protocols.
My take away from this is that being checked off on a process and going through the motions of a checkoff can be greatly influenced by the culture of the environment.

3. From the following selections which shaped the root cause discussions at both hospitals, teams selected the red highlighted statements as the two best root causes:

a. Chairman of Surgery is clearly the biggest contributor to the problem, and is the single root cause, since he caused the near miss/sentinel event.

b. The culture in our OR suite is not conducive to patient safety.

c. The disruptive physician policy at our organization is ineffective in shaping physician behavior. It needs to be re-written.

d. The Nursing/Physician relationships in our OR suites are compromised by poor communication skills, ineffective conflict resolution, and no sense of team.

e. From CNO down through nurse managers, the nursing leadership at our organization is ineffective

f. Educational offerings regarding the NPSGs, Universal Protocol, and Time-out procedures are clearly lacking, and the single most important root cause of these events.

g. The turnaround time between cases is reaching crisis proportions and surgical volume is on a downward trend in both of these hospitals

4. Defend the teams' position on the choice of these two; however, if you, as a case study team choose alternative root causes from this list given the data presented, defend that position.

Reflecting with my statement in question #2: training in procedures and checkoffs on procedures does not guarantee the outcomes. The culture of safety is related to the ability to communicate freely between all present staff.

In week 9 the case study team assumes full senior leader support on the validation of the two root causes identified.

1. Review the literature to find at least 4 peer reviewed research studies which evoke validation of the latest patient safety evidence in support of your root cause finding.

(Only select 1 peer-reviewed article and post the citation here. Must be less than 5 years old)

REMAINDER OF DISCUSSION CONTRIBUTION TO FOLLOW TO ADDRESS BELOW:

2. At this point, the case study team determines recommendations using the latest evidence from the literature on what is needed within these two hospitals to address these significant root causes.

3. Assume a three-month implementation timeframe, recognizing that full realization may take longer.

4. Construct a straw man Gantt chart or project plan to capture all necessary components to move the recommendations forward.

Assure that the project plan is detailed and thorough, and addresses at the minimum "who will do what by when". Although an excel spreadsheet or a WORD document will work fine, consider use of any project planning software package and convert final document to a pdf as evidence of the week's discussion.

The case study team determines a measurement mechanism that is more likely to be predictive of preventing a similar occurrence of wrong patient or wrong side surgery.

Two components comprised ongoing measurement mechanisms that these hospitals and surgi-centers have relied on across the system.

These include the two graphs presented in the case study presentation. Revisit those graphs and the data collection processes that they represent.

1. Critique those processes as ongoing measures of time-out/UP effectiveness.

2. Suggest at least one alternative data collection mechanism suitable for the perioperative dashboard.

3. The team members are debating between surgical volume (which, as mentioned, had been declining) and turnover time between cases as a measure connecting to the balanced scorecard across the system. What is your opinion? Defend your choice with references from peer reviewed literature. Explain within the course of your discussion how your choice is related to these two cases and to the ultimate resolution.

As a case study team, prepare a 10-slide power-point using tools provided in this case study to present your rationale and validation of these two root causes. Be sure to include at least 4 peer reviewed research studies which evoke validation of the latest patient safety evidence in support of your root cause findings.

Attachment:- Case Study.rar