How factor might have contributed to the wrong-limb surgery


Homework: Application of Root Cause Analysis

As you have examined in this course, errors and mishaps, although not frequent, do occur in health services organizations. While the aim is to deliver effective and quality care, errors due to systems processes or inefficient system checks still exist. As a current or future health care administration leader, applying process tools to analyze and determine the causes of such errors will likely impact initiatives aimed at fostering health care quality and safety.

For this Homework, review the resources for this week that are specific to RCA. Reflect on the AHRQ article regarding factors that may lead to latent error and the New York Times article regarding the doctor who removed the wrong limb from a patient. Think about recommendations you might make to prevent errors such as these from occurring in your health services organization.

Task: (3 to 4 pages)

1) Briefly summarize the salient facts of the New York Times article.

2) Using the AHRQ table regarding factors that may lead to latent error, assess how each factor might have contributed to the wrong-limb surgery.

3) Qualitatively assess how much each factor contributed to the error.

4) Provide recommendations that you believe would present such an event from occurring again, and explain why you made these recommendations. Be specific and provide examples.

Format your homework according to the following formatting requirements:

(1) The answer should be typed, double spaced, using Times New Roman font (size 12), with one-inch margins on all sides.

(2) The response also includes a cover page containing the title of the homework, the student's name, the course title, and the date. The cover page is not included in the required page length.

(3) Also include a reference page. The Citations and references should follow APA format. The reference page is not included in the required page length.

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