case analysis 141

Case Analysis (Individual) –Quality/Patient Safety Improvement Plan: Students will be assigned a case that they need to analyze utilizing QI tools taught in the class. Cases/Scenarios will be provided in class and students will use the information and data provided within the case and specific QI/PS tools and techniques to address the problem at hand. Deliverables will include a QI/Patient Safety Case Analysis that addresses – what happened (incident), why it happened (contributory factors), key contributory factors (two to three), recommendations to address the key contributory factors (with evidence to support effectiveness of interventions), measures to assess improvement and rationale. Students will provide charts, graphs and use the learning from defects tool and other tools from class – fish bone, pareto chart etc. Length of the paper: The case analysis should be between six to eight pages (double spaced) excluding appendices, cover page, and references.You must use sub-headings e.g. what happened, why/contributory factors, key contributory factors that led to the event, recommendations to address key contributory factors and rationale, measures to assess improvement and conclusion.Please refer to detailed instructions on the course blackboard.
The Learning from Defects (LFD) tool was developed at Johns Hopkins by Prof. Peter Pronovost and his team at the former Quality and Safety Research Group. Students should use this tool to systematically investigate:1. What happened – A clear, thorough and objective explanation of ‘what happened”2. Why did it happen? – Review the list of factors that contributed either positively or negatively to the incident. Rate the MOST IMPORTANT factors that relate to the incident.3. Describe how you will reduce the likelihood of this defect/event happening again. See the tables. Develop/Suggest interventions for each IMPORTANT contributory factor and rate each intervention for its ability to mitigate the defect and ability to be implemented. Identify 2-5 interventions that you will implement. List WHAT you will do, WHO will lead the intervention and WHEN you will follow up on the intervention to review progress.4. Describe how and when you know that you have reduced the risk. What measures will indicate progress.

-I just want to mention that the professor told us not to write for example 3 pages for just the first question (what happened). Also, use charts in the paper. I will attach a powerpoint file that contain all the info.