Assignment: Communication problems

Post a response that addresses the following questions for the case you have chosen:

ü In what way did the system fail the patient and his family?

ü What communication problems are apparent in the case?

ü Where in the process of care did incidents (errors, near misses, adverse events, and harm) occur?

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Nurse executives may be tasked with evaluating adverse safety events—either individually or as part of an interdisciplinary team—to prevent them in the future. An evaluation may consist of analyzing every step in the patient’s care process to see what did and did not occur. Tools like the process map allow this kind of step-by-step view.

For this assignment, you will read about two real cases that resulted in negative outcomes and—much like a root cause analyst—examine what went wrong from a quality and safety standpoint.

Post a response that addresses the following questions for the case you have chosen:

· In what way did the system fail the patient and his family?

· What communication problems are apparent in the case?

· Where in the process of care did incidents (errors, near misses, adverse events, and harm) occur?

Learning Resources

Patient Safety Movement. (n.d.). Patient story: Lewis Blackman. Retrieved from https://patientsafetymovement.org/advocacy/patients-and-families/patient-stories/lewis-blackman/

Johnson, J., Haskell, H., & Barach, P. (2009). Lewis’ story—It’s hard to kill a healthy 15-year-old. Retrieved from http://www.healthwatchusa.org/conference2013/PDF-Downloads/Haskell-Lewis_Blackman_Story.pdf

Institute for Healthcare Improvement. (n.d.c). Noah’s story: Are you listening? Retrieved from http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/NoahsStoryAreYouListening.aspx

Ricciardi, R., & Shofer, M. (2019). Nurses and patients: Natural partners to advance patient safety. Journal of Nursing Care Quality, 34(1), 1–3.

Agency for Healthcare Research and Quality. (2019e). Systems approach. Retrieved from https://psnet.ahrq.gov/primer/systems-approach

You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.

Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.

Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.

The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.