TOPIC: Root cause analysis for Fall Risk patient that led to Fall injuries, As

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TOPIC: Root cause analysis for Fall Risk patient that led to Fall injuries,
Assuming dealt with it in HOSPITAL Setting
The purpose of this assignment is to assist the student to acquire skills in analyzing the causes associated with a sentinel event or error in practice (fall injuries).
A root cause analysis focuses primarily on systems and processes, not on individual performance. The student will gain knowledge and understanding of the underlying mechanisms which accompany untoward events and will develop a plan of action to prevent a repeat occurrence.
Identify a clinical practice error that occurred in hospital setting (topic is fall Injuries) . Disguise
the specific circumstances of the situation so that the parties involved cannot be identified, including the healthcare agency. APA format, Minimum of 5 peer reviewed resources.
1. Intro (1 slide) : Introduction
2.Incident Description [1 slide] Use this section to describe the incident and its consequences, using
only the facts.
3. Type of Investigation undertaken [2 slides]: Use this section to describe the methods used during
the investigation –the 5 WHYs and your diagram.
4. Findings [1 slide] : Use this section to describe the care delivery or service delivery problems and what the contributing factors were found to be.
5. Positive Features and Good Practice [1 slide] : Use this section to highlight any positive features,
good practice or actions that reduced the severity of the incident.
6. Recommendations and Action Plan (1 slide): Follow the Joint Commission format for development
of the action plan
7. Conclusion ( 1 slide)
Refrence slide: minimal 5 peer reviewed resources
NOTE: Follow APA guidelines for reference list, tables, etc.
Access information on root cause analysis on the Joint Commission on
Accreditation of Healthcare Organizations website: jointcommission.org/. The
specific forms needed are located under the category “sentinel event.” Select “forms
and tools.” Specifically you will need the “Root Cause Analysis Matrix,” and the “Framework
for Conducting a Root-CauseAnalysis and Action Plan.” The matrix gives
examples of specific types of sentinel events with a heavy emphasis on the
occurrences in the acute care setting, but will apply equally in other settings. The
framework form can be downloaded and saved to disk (the name of the document
is rcaframework.doc).
http://www.jointcommission.org/Framework_for_Conducting_a_Root_Cause_Analysis_
and_Action

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