josie king case analyse
Description
HCMN 435 Patient Safety Case Analysis Paper – Instructions
Instructions: First read the case you have chosen from the case repository on blackboard thoroughly AND review the Learning from Defects tool provided. This tool was developed and adapted by the Quality and Safety Research Group led by Professor Pronovost et al to help health care providers identify and learn from defects utilizing a systems approach. The contributory factors framework helps providers gain a deeper appreciation of harm as it occurs usually due to breakdown of systems (multiple factors).It steers clear of blame and punitive behavior and encourages teams to focus on learning.
Attempt ALL four questions in response to the case provided below as though you are part of the team investigating.What happened, why (contributory factors), key contributory factors that led to the event. Be sure to categorize your contributory factors into patient factors, caregiver factors, task, teamwork and communication etc.Please use QI tools such as flow chart, cause and effect/fishbone and pareto charts to justify your interventions.These charts should be part of your appendices.Suggest interventions so that such events will not occur in the future (be sure that the interventions you suggest address the key contributory factors).Then provide measures that you will assess to know if your suggested interventions are working.Assume that you have implemented your recommendations. How will you know that these worked to reduce/eliminate risk? What measures would help confirm improvements.Please include an abstract as your first page and include titles and sub-titles (e.g. what happened, why (contributory factors), key contributory factors etc.
Try to be objective and use facts from the case. It is recommended that you take time reading the case and ascertain key contributory factors prior to suggesting any intervention. You may use additional sheets of paper to make rough notes, provide your rationale for choices/additional descriptions, flow chart etc. You should prepare an outline first for your case analysis.Feel free to visit your instructor during office hours for any questions that you may have concerning this assignment.
Format and page length: APA 6.0 format, and between 6-8 pages excluding appendices and cover page see syllabus for other details.
Grading Rubric:Your responses will be graded on the basis of clarity of thought, originality, accuracy and specificity of content, and the approach utilized in analyzing the defect and providing recommendations.
Possible maximum points by question:
Question # 1 (10 points),
Question # 2 (40 points),
Question # 3 (40 points),
Question # 4 (10 points).
Total = 100 points
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References:
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Guideline Adaption Committee. (2016). Clinical practice guidelines and principles of care for people with dementia. NHMRC Partnership Centre for Dealing with Cognitive and Related Function Decline in Older People. https://cdpc.sydney.edu.au/wp-content/uploads/2019/06/CDPC-Dementia-Guidelines_WEB.pdf
Living Guideline
Stroke Foundation. (2022). Australian and New Zealand living clinical guidelines for stroke management – chapter 1 of 8: Pre-hospital care. https://app.magicapp.org/#/guideline/NnV76E
Evidence-based practice
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Swe, K. K. (2022). Blood glucose levels: Self-monitoring [Evidence summary]. JBI EBP Database. https://jbi.global
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Bellman, S. (2022). Experiences of living with juvenile idiopathic arthritis [Best practice information sheet]. JBI EBP Database, 24(1), 1-4.
Cochrane Database of Systematic Reviews
Srijithesh, P. R., Aghoram, R., Goel, A., & Dhanya, J. (2019). Positional therapy for obstructive sleep apnoea. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD010990.pub2
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Codeine. (2023, January). In Australian medicines handbook. Retrieved February 2, 2023, from https://amhonline.amh.net.au
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Perth Children’s Hospital. (2022, April). Appendicitis [Emergency Department Guidelines]. Child and Adolescent Health Service. https://www.pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Appendicitis
Department of Health. (n.d.). Who is being active in Western Australia? https://ww2.health.wa.gov.au/Articles/U_Z/Who-is-being-active-in-Western-Australia
Donaldson, L. (Ed.). (2017, May 1). Healthier, fairer, safer: The global health journey 2007-2017. World Health Organisation. https://www.who.int/publications/i/item/9789241512367
NCBI Bookshelf
Rodriguez Ziccardi, M., Goyal, G., & Maani, C. V. (2020, August 10). Atrial flutter. In Statpearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK540985/
Royal Perth Hospital. (2016). Procedural management: Pre and post (24-48 hours) NPS. Canvas. https://courses.ecu.edu.au
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