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.

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 Discussion, 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.

To Prepare:

Read about both the Lewis Blackman and Noah Lord cases in the Learning Resources. Select one on which to write your initial post.

By Day 3 of Week 5

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?

Note:?For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on?Submit!

Read a selection of your colleagues’ responses.

By Day 6 of Week 5

Respond to at least two of your colleagues on two different days, ensuring that you respond to at least one Lewis Blackman and at least one Noah Lord case analysis. 

Respectfully agree or disagree with your colleague’s analysis of the case. Additionally, make a recommendation for quality improvement and explain how it would address the identified problems