After being admitted a medication ,25 years old male experience extreme nausea and vomiting which resulted in
a prolong stay in the hospital. On initial investigation it appeared the original order was for three times
the recommended dose.
1. Adverse Event Type
i. Mild Harm
ii. Moderate ? Severe Harm
c. Near Miss
1. Classification by Causes
2. Write a Combine shared Vision and Need statement
a. Brainstorm on Opportunities and Threats prevent
i. What are the consequences if you do not prevent these events?
ii. What are the benefits if you prevented these events?
b. Vision Statement:
i. Is the vision motivating and energizing?
ii. What are the things you want the improvement to be known for patients?
iii. What are the words which describe what your patients would see, hear, or feel if the prevention efforts
i. Who are the key stakeholders affected by this initiative, and how much importance dose each give to the
ii. Have we framed the need for change in such a way to reflect the concerns of patients and stakeholders?
iii. Would each team member deliver essentially the same message regarding the need for the change if asked by
someone outside of the team?
iv. Why must you prevent these events?
3. Write Elevator Speech for Disclosure to patient
a. Our AIM of our investigation is to ?
b. The investigation into root causes is important because?
c. Results of our investigation will be disclosed to you in the following way?
4. Design a One Page Event Reporting Form
a. patient demographics and characteristics
b. checklist for different levels of harm from the event
c. checklist for at least four categories of independent variables describing how total events are distributed
i. clinical unit
ii. staff disciplines
iii. different processes such as medication administration
d. finalize report form with all data elements
5. Data Collection and Analysis on One Year of Simulated Number of Events.
a. Prepare summary table for monthly number of events for 12 months
i. Refer to sample Excel worksheet provided by consultant
ii. Refer to Excel sample trend line and bar graphs prepared by consultant
6. Review the J.C.I. Project Charter
a. complete charter as homework assignment
7. Develop a process Mapping on Flip Chart
a. High level horizontal map limited to 5 process steps
i. Optional: use SIPOC to design process map
8. Root Cause Analysis:
a. Use fishbone diagram to identify and list at least 5 different types of root causes: people, equipment,
b. Start with proximate cause and use 5 why analysis inquiry among team members to develop root cause
9. Develop Solutions
a. Develop one solution or prevention strategy for each root cause
b. use effective- achievable decision matrix to categorize and prioritize each solution action plan
10. Action Plans
a. Complete a WWW action plan tool
b. incorporate this into quality management report for home work assignment
12. Write a quality management report
a. use the A 3 report format
b. start with a complete JCI charter
c. use information documented during the course
d. End with a completed JCI WWW
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