Instructions
By now you should have received feedback on your first milestone to incorporate into your project. Moving on to the next step, in this section you will consider disclosure and incident reporting systems that would apply to your chosen case study.
For additional details, please refer to the Milestone Two Guidelines and Rubric PDF document and the Final Project Guidelines and Rubric PDF document.
IHP 315 Milestone Two Guidelines and Rubric
In Milestone One, you identified your case study, conducted a root cause analysis, and drafted some patient safety strategies to address the issues in the case
study. For this second milestone, you will consider disclosure and incident reporting systems that would apply to your case study. In this milestone the following
critical elements must be addressed:
III. Disclosure: In this section, you will develop key elements of disclosure and incident reporting systems. Specifically, you should cover the following:
A. Details: Based on state and federal reporting requirements and the results of the root cause analysis (RCA), identify the details that would be
necessary to disclose the error to the patient and family.
B. Method and Preparation: How would you suggest disclosing these details to the patient and family? What preparation would be needed for the
staff, patient, and family before the disclosure?
C. Reporting: What elements of the RCA and corrective action plan (strategies) would need to be shared with accrediting or regulatory agencies?
For example, what elements should be reported to the State Department of Health and Human Services? What should be reported to The Joint
Commission?
Guidelines for Submission: Your submission should be 1 to 2 pages in length
IHP 315 Final Project Guidelines and Rubric
Overview
The final project for this course is an error analysis and recommendations paper. Students will review a case study that discusses a medical error leading to an
adverse patient outcome in a hospital or other healthcare organization. Students will determine the type of error that occurred and its causal and contributing
factors, and then recommend strategies that can be used to lower the incidence of the error.
The final product represents an authentic demonstration of competency because it reflects the IHP 315 course objectives. The project is divided into three
milestones, which will be submitted at various points throughout the course to scaffold learning and ensure quality final submissions. These milestones will be
submitted in Modules Two, Four, and Five. The final product will be submitted in Module Seven.
In this assignment, you will demonstrate your mastery of the following course outcomes:
Recommend measurable evidence-based patient safety improvement strategies through analysis of factors leading to adverse patient outcomes
Develop key elements of disclosure and incident reporting systems that address the needs of patients, families, and healthcare systems and are
consistent with state and federal reporting requirements
Analyze patient safety culture using appropriate assessment tools for recommending methods to effectively improve culture
Propose essential communication and teamwork strategies that are measurable and promote safer patient care in healthcare organizations
Prompt
In your error analysis and recommendations paper you will answer the following question. What caused the medical error that occurred, and how would you
suggest that the error could be prevented from happening again? To answer this guiding question, you will analyze the medical error in the case study you
choose from the Final Project Case Studies document.
Specifically, the following critical elements must be addressed:
I. Root Cause Analysis (RCA): In this section, you will provide an overview of the details in the provided case study that led to adverse patient outcomes.
This overview will be in the form of a flowchart, which you will then use to help you analyze the medical error. Specifically, you should include the
following:
A. Timeline: Using a flowchart, summarize the events, processes, and staff involved in the timeline of events that led to the medical error.
B. Factors: Based on your flowchart, use a modified root cause analysis to do the following:
i. Identify two contributing factors that led to the medical error
ii. Identify one causal factor that led to the medical error
II. Patient Safety Strategies: In this section, you will use the factors you identified to recommend a measurable evidence-based patient safety improvement
strategy. Specifically, you should include the following:
A. Recommendation: Based on the contributing factors or causal factor that you identified, recommend an evidence-based patient safety
improvement strategy. What role would patients and families have in your recommendation?
B. Measurement: How will the strategy be measured so that medical staff can determine whether the strategy led to improved patient safety? In
other words, what will the primary measure be? What types of data should be collected?
III. Disclosure: In this section, you will develop key elements of disclosure and incident reporting systems. Specifically, you should cover the following:
A. Details: Based on state and federal reporting requirements and the results of the root cause analysis (RCA), identify the details that would be
necessary to disclose the error to the patient and family.
B. Method and Preparation: How would you suggest disclosing these details to the patient and family? What preparation would be needed for the
staff, patient, and family before the disclosure?
C. Reporting: What elements of the RCA and corrective action plan (strategies) would need to be shared with accrediting or regulatory agencies?
For example, what elements should be reported to the State Department of Health and Human Services? What should be reported to The Joint
Commission?
IV. Patient Safety Culture: In this section, you will analyze patient safety culture through the use of a survey as an assessment tool. Specifically, you should
address the following:
A. Analysis: Analyze all of the patient safety culture survey results at the facility where the error occurred. These results are in your Final Project
Case Studies document. What does this survey tell you about the patient safety culture at the facility? Based on your analysis, what are the
areas for improvement?
B. Outcome: In what ways might the outcome have been different if the facility had a stronger patient safety culture? Your response should be
based on your analysis of the patient safety culture survey.
C. Recommendation: Recommend one method that could be used to improve the patient safety culture. Justify your recommendation with your
analysis of the survey.
V. Communication: In this section, you will propose communication and teamwork strategies, explaining how these strategies promote safer patient care.
Specifically, you should address the following:
A. Strategy: What strategy or strategies could be used to improve communication and team building? Explain why you selected the strategy or
strategies, basing your response on your analysis of the medical error and the patient safety culture.
B. Safer Patient Care: How does the strategy (or strategies) promote safer patient care? What evidence do you have to support your response?
C. Measurement: How will the communication and teamwork strategy or strategies be measured? In other words, how will we know that
communication improved?
Milestones
Milestone One: Root Cause Analysis and Patient Safety Strategies
In Module Two, you will select one of the case studies provided in the Final Project Case Studies document to be the focus of your entire project. You will then
complete a root cause analysis and recommend appropriate patient safety strategies. This milestone will be graded with the Milestone One Rubric.
Milestone Two: Disclosure
In Module Four, you will consider disclosure and incident reporting systems that would apply to your chosen case study. This milestone will be graded with the
Milestone Two Rubric.
Milestone Three: Patient Safety Culture and Communication
In Module Five, you will develop your analysis of the patient safety culture of your chosen case study and then propose communication and teamwork strategies
to promote patient safety initiatives within your organization. This milestone will be graded with the Milestone Three Rubric.
Final Submission: Error Analysis and Recommendations Paper
In Module Seven, you will submit your final project. It should be a complete, polished artifact containing all of the critical elements of the final product. It should
reflect the incorporation of feedback gained throughout the course and be APA formatted and referenced. This submission will be graded with the Final Project
Rubric.
