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Error Analysis and Recommendations
Error Analysis and Recommendations
Twenty-year-old student developed a right-sided pneumothorax while playing soccer. He had no prior remarkable medical history. A chest film confirmed a right lower-lobe pneumothorax. The doctor ordered a thoracotomy insertion tray as soon as the equipment was provided at the bedside, the nurse inserted the chest tube into Paulâs left side. As time was of the essence, no consent was signed and a time out, usually performed in surgery, was also not done. Following the chest tube insertion, there was no improvement in Paulâs shortness of breath. At this time, the nurse informed the physician that the chest tube had been inserted on the wrong side.The nurse noted in Paulâs record that an incident report was filed for the wrong-side insertion, following the doctorâs written order to do so. The emergency physician attempted to have Paul admitted as an inpatient to Union Hospital so that the reinsertion could be done in the operating room. The nursing supervisor informed the physician that there were no available inpatient beds at Union and Paul would need to be transported and admitted to Jefferson Memorial, five minutes away. As an ambulance was on standby at Union, the physician ordered immediate transport and also communicated with the surgeon at Jefferson about Paulâs condition. The unit secretary had just returned from taking a late lunch break and did not see the transfer order. The nurse was admitting another patient to the emergency department. Paul oxygenation status continued to decompensate and he lost consciousness. At 1430, the secretary noticed the order and clarified with the nurse. When the nurse went to reassess Paul, he had expired. The physician has professional liability insurance as a condition of his employment at Union. The nurse does not. Final Paper Requirements: 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 embedded in your 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 strategies could be used to improve communication and team building? Explain why you selected the strategies, basing your response on your analysis of the medical error and the patient safety culture. B. Safer Patient Care: How does the strategy 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 improve
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Are book shops, logicians, ministers and all others selling a book that they are being wolves in sheep’s clo Error Analysis and Recommendations thing about? Would they wager on this reality, or is it a paradox, for example, a “Hurried speculation “to state, since the book was composed by men who have firsthand learning or wer Error Analysis and Recommendations e roused by God, there are no mix-ups. It is certainly conceivable that at least one of the Biblical essayists could have been smashed, nodded off, was furious or just too sluggish to even think about editting appropriately and speck each “I” and cross each “T”. For if there is one example of disarray that can be called attention to, for example, that found in the tale of the Last Supper and Crucifixion, at that point we can without much of a stretch accept that there are more case Error Analysis and Recommendations s, some of which I will plot und Error Analysis and Recommendations erneath. We should take a gander at some other conflicting stories in the holy book. The tale of Cain and Abel is one that shouts “inconsistency”: After killing his sibling, Cain keeps running off and shacks up with another lady Genesis 4:16-17[11] layouts that Cain proceeded to get a spouse, as of now, his mom Eve was the ma Error Analysis and Recommendations in thing on Earth with human ovaries. Who was that lady and where did she originated from? The passing of Judas is another flawed story, how could He kick the bucket? Did he bite the dust twice, The New Testament claims Judas both hanged himself (Matthew 27:5 Error Analysis and Recommendations )[12] and detonated subsequent to falling over( Acts 1:18 ? Which is right? Ezekiel 16:49 makes it quite clear the individuals of Sodom were executed for being covetous and ungracious to poor people, as does Amos 4:1-11[13] and Jeremiah 23:14 .[14] This is exceptionally odd since we perused in different sections that the Israelites were insatiable when they gathered more Manna than they required Error Analysis and Recommendations for one day, however were reproved, not killed. Does the Bible recount a God with various characters or more than one god? There is just one genuine and living God, however the feeling that can emerge out of this reality is that He manages various people contrastingly for the exceptionally same wrongdoing. As Sam Harris sketched out in “Letter to a Christian Nation” In discussing the great results that our convictions have on human ethical quality, we are following the instances of religious nonconformists and religious moderates.[15] He further expressed that “these conservatives and dissidents will in general talk as far as the great results as accepting as they do”. This is normally managed without giving proof regarding why we should. The Bible expressed that when God was looked with a city of gay people in Sodom, some of whom attempted to make out with the blessed messengers, God flies into an anger and blows the entire spot up. BUTââ¬Â¦. Looked with his hireling Lot having intoxicated sex with his girls, God has no issues with it. Part was not rebuffed, he was permitted to return to rest after the de Error Analysis and Recommendations monstration. Is the God of the Bible twofold disapproved or is it that the Story teller missed some significant realities? Since this is one increasingly Biblical story does not bode well and prompts my decision that the good book isn’t dependable. Some Bible essayists make it a mission to “Toxic substance the Well”, how about we take a gander at the narrative of Moses, as He drove the Children of Israel ou Error Analysis and Recommendations t of Egypt and into the Promised Land. God portrayed them as a “Willful individuals “I have seen these individuals,” the LORD said to Moses, “and they are a persistent people”. These individuals were marked as being discourteous and wild, in this way they didn’t get an opportunity with Moses who utilized His awful temper to shout, pitch fits and toss things around. Does this sound true? Moses who was recently alluded to as being modest and unfit to Error Analysis and Recommendations talk unmistakably for himself all of a sudden turned into this mythical beast sort of fellow, breaking Covenant plates, striking rocks and so forth. Amazing, what a change. These are a portion of the reasons why I am of the conclusion that a man composed book of scriptures can’t be faultless 1. On the off chance that Men are untrustworthy, at that point the Bible is likewise frail: 2. Men are known to have aced numerous everyday issues; a portion of the Error Analysis and Recommendations se territories are Industrial, science, prescription and Agriculture. 3. As far as Inventions at regular intervals we read of new items that turn out available, and from time to time we read of the imperfections and reviews. These are not many of the models that demonstrates that man is uncertain and thu>
Are book shops, logicians, ministers and all others selling a book that they are being wolves in sheep’s clothing about? Would they wager on this reality, or is it a paradox, for example, a “Hurried speculation “to state, since the book was composed by men who have firsthand learning or were roused by God, there are no mix Error Analysis and Recommendations -ups. It is certainly conceivable that at least one of the Biblical essayists could have been smashed, nodded off, was furious or just too sluggish to even think about editting appropriately and speck each “I” and cross each “T”. For if there is one example of disarray that can be called attention to, for example, that found in the tale of the Last Supper and Crucifixion, at that point we can without much of a stretch accept that there are more cases, some of which I will plot underneath. We shou Error Analysis and Recommendations ld take a gander at some other conflicting stories in the holy book. The tale of Cain and Abel is one that shouts “inconsistency”: After killing his sibling, Cain keeps running off and shacks up with another lady Genesis 4:16-17[11] layouts that Cain proceeded to get Error Analysis and Recommendations a spouse, as of now, his mom Eve was the main thing on Earth with human ovaries. Who was that lady and where did she originated f Error Analysis and Recommendations rom? The passing of Judas is another flawed story, how could He kick the bucket? Did he bite the dust twice, The New Testament claims Judas both hanged himself (Matthew 27:5)[12] and detonated subsequent to falling over( Acts 1:18 ? Which is right? Ezekiel 16:49 makes it quite clear the individuals of Sodom were executed for being covetous and ungracious to poor people, as does Amos 4:1-11[13] and Jeremiah 23:14 .[14] This is exceptionally odd since we perused in different sections that the Israelites were insatiable when they gathered more Manna than they required for one day, however were reproved, not killed. Does the Bible recount a God with various characters or more than one god? There is just one genuine and li Error Analysis and Recommendations ving God, however the feeling that can emerge out of this reality is that He manages various people contrastingly for the exceptionally same wrongdoing. As Sam Harris sketched out in “Letter to a Christian Nation” In discussing the great results that our convictions have on human ethical quality, we are following the instances of religious nonconformists and religious moderates.[15] He further expressed that Error Analysis and Recommendations “these conservatives and dissidents will in general talk as far as the great results as accepting as they do”. This is normally managed without giving proof regarding why we should. The Bible expressed that when God was looked with a city of gay people in Sodom, some of whom attempted to make out with the blessed messengers, God flies into an anger and blows the entire spot up. BUTââ¬Â¦. Looked with his hireling Lot having intoxicated sex with his girls, God has no issues with it. Part was not rebuffed, he was permitted to return to rest after the demonstration. Is the God of the Bible twofold disapproved or is it that the Story teller missed some significant realities? Since this is one increasingly Biblical story does not bode well and prompts my decision that the good book isn’t dependable. Some Bible essayists make it a mission to “Toxic substance the Well”, how about we take a gander at the narrative of Moses, as He drove Error Analysis and Recommendations the Children of Israel out of Egypt and into the Promised Land. God portrayed them as a “Willful individuals “I have seen these individuals,” the LORD said to Moses, “and they are a persistent people”. These individuals were marked as being discourteous and wild, in this way they didn’t get an opportunity with Moses who utilized His awful temper to shout, pitch fits and toss things around. Does this sound true? Moses who was recently alluded to as being modest and unfit to talk unmistakably for himself all of a sudden turned into this mythical beast sort of fellow, breaking Covenant plates, striking rocks and so forth. Amazing, what a change. These are a portion of the reasons why I am of the conclusion that a man composed book of scriptures can’t be faultless 1. On the off chance that Men are untrustworthy, at that point the Bible is likewise frail: 2. Men are known to have aced numerous everyday issues; a portion of these territories are Industrial, science, prescription and Agriculture. 3. As far as Inventions at regular intervals we read of new items th Error Analysis and Recommendation Error Analysis and Recommendations s at turn out available, and from time to time we read of the imperfections and reviews. These are not many of the models that demonstrates that man is uncertain and thu>
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