Identify an error or near miss (close call) that you have encountered in the clinical practice setting. Consider the impact of the error on patient outcomes. For example, was the error disclosed to the patient and family, how did administration respond to the error initially and were strategies implemented to prevent the error or near miss from occurring again. Please do not identify the healthcare agency where the error occurred or individuals involved (HIPAA). Elaborate on how the error made you feel. What thoughts and fears did it provoke in you?
As you reflect on this event, use the concepts related to a “Just Culture” (ppt presentation from David Marx) and the proactive approach of “ Failure Mode Effects Analysis” (resource provided from Institute on Healthcare Improvement) and share how as a nurse leader /manager that you would address this safety concern in the healthcare organization. Discuss in detail the idea of “second victim” and how as a manager you could provide support to your staff and promote a “just culture”. Use scholarly in text citations to support your decisions.
Develop a narrated/voice over/recorded powerpoint presentation discussing the error/near miss and incorporate the ideas from David Marx’s ppt and the Failure Mode Effects Analysis on resolving the issue, second victim, and a managers role in handling this safety concern. Upload your narrated powerpoint in the discussion forum area as your initial post and then reply to a minimum of four of your peers. (Follow the grading rubric and do not forget to include a reference slide at the end of your powerpoint.)
http://www.ihi.org/resources/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx
