Project Paper

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